Fiscal Year 2017–2018 Site Review Report for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
January 2018
This report was produced by Health Services Advisory Group, Inc., for the Colorado Department of Health Care Policy and Financing.
Table of Contents
1. Executive Summary ...... 1-1 Summary of Results ...... 1-1 Standard V—Member Information ...... 1-4 Summary of Strengths and Findings as Evidence of Compliance ...... 1-4 Summary of Findings Resulting in Opportunities for Improvement ...... 1-4 Summary of Required Actions ...... 1-4 Standard VI—Grievance System ...... 1-5 Summary of Strengths and Findings as Evidence of Compliance ...... 1-5 Summary of Findings Resulting in Opportunities for Improvement ...... 1-6 Summary of Required Actions ...... 1-7 Standard VII—Provider Participation and Program Integrity ...... 1-8 Summary of Strengths and Findings as Evidence of Compliance ...... 1-8 Summary of Findings Resulting in Opportunities for Improvement ...... 1-9 Summary of Required Actions ...... 1-9 Standard IX—Subcontracts and Delegation ...... 1-9 Summary of Strengths and Findings as Evidence of Compliance ...... 1-9 Summary of Findings Resulting in Opportunities for Improvement ...... 1-10 Summary of Required Actions ...... 1-10 2. Overview and Background ...... 2-1 Overview of FY 2017–2018 Compliance Monitoring Activities ...... 2-1 Compliance Monitoring Site Review Methodology ...... 2-1 Objective of the Site Review ...... 2-2 3. Follow-Up on Prior Year's Corrective Action Plan ...... 3-1 FY 2016–2017 Corrective Action Methodology ...... 3-1 Summary of FY 2016–2017 Required Actions ...... 3-1 Summary of Corrective Action/Document Review ...... 3-1 Summary of Continued Required Actions ...... 3-2 Appendix A. Compliance Monitoring Tool ...... A-1 Appendix B. Record Review Tools ...... B-1 Appendix C. Site Review Participants ...... C-1 Appendix D. Corrective Action Plan Template for FY 2017–2018 ...... D-1 Appendix E. Compliance Monitoring Review Protocol Activities ...... E-1
Access Behavioral Care FY 2017–2018 Site Review Report Page i State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
1. Executive Summary
The Code of Federal Regulations, Title 42—federal Medicaid managed care regulations, published May 6, 2016—requires that states conduct a periodic evaluation of their managed care organizations (MCOs) and prepaid inpatient health plans (PIHPs) to determine compliance with federal healthcare regulations and managed care contract requirements. The Department of Health Care Policy and Financing (the Department) has elected to complete this requirement for Colorado’s behavioral health organizations (BHOs) by contracting with an external quality review organization (EQRO), Health Services Advisory Group, Inc. (HSAG).
In order to allow for implementation of new federal managed care regulations published May 2016, the Department determined that the review period for FY 2017–2018 was July 1, 2017, through December 31, 2017. This report documents results of the FY 2017–2018 site review activities for both Access Behavioral Care—Denver (ABC-D) and Access Behavioral Care—Northeast (ABC-NE). For each of the four standard areas reviewed this year, this section contains summaries of the findings as evidence of compliance, strengths, findings resulting in opportunities for improvement, and required actions. Section 2 describes the background and methodology used for the 2017–2018 compliance monitoring site review. Section 3 describes follow-up on the corrective actions required as a result of the 2016–2017 site review activities. Appendix A contains the compliance monitoring tool for the review of the standards. Appendix B contains details of the findings for the appeals and grievances record reviews. Appendix C lists HSAG, BHO, and Department personnel who participated in some way in the site review process. Appendix D describes the corrective action plan process the BHO will be required to complete for FY 2017–2018 and the required template for doing so. Appendix E contains a detailed description of HSAG’s site review activities consistent with the Centers for Medicare & Medicaid Services (CMS) final protocol.
Summary of Results
Based on conclusions drawn from the review activities, HSAG assigned each requirement in the compliance monitoring tool a score of Met, Partially Met, Not Met, or Not Applicable. HSAG assigned required actions to any requirement within the compliance monitoring tool receiving a score of Partially Met or Not Met. HSAG also identified opportunities for improvement with associated recommendations for some elements, regardless of the score. Recommendations for requirements scored as Met did not represent noncompliance with contract requirements or federal healthcare regulations.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
Table 1-1 presents the scores for ABC-D for each of the standards. Findings for requirements receiving a score of Met are summarized in this section. Details of the findings for each requirement receiving a score of Partially Met or Not Met follow in Appendix A—Compliance Monitoring Tool.
Table 1-1—Summary of ABC-D Scores for the Standards # of # Score # of Applicable # Partially # Not # Not (% of Met Standards Elements Elements Met Met Met Applicable Elements) V. Member Information 12 11 6 5 0 1 55% VI. Grievance System 27 27 24 3 0 0 89% VII. Provider Participation 13 13 12 1 0 0 92% and Program Integrity IX. Subcontracts and 4 4 4 0 0 0 100% Delegation Totals 56 55 46 9 0 1 84% Note: While scoring related to individual, new federal requirements in the tool may indicate Met or Not Scored, all new requirements were scored Not Applicable in the total results; new federal requirements do not apply to CHP+ until July 1, 2018. *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements.
Table 1-2 presents the scores for ABC-D for the record reviews. Details of the findings for the record reviews are in Appendix B—Record Review Tools.
Table 1-2—Summary of ABC-D Scores for the Record Reviews # of Score # of Applicable # # Not # Not (% of Met Record Review Elements Elements Met Met Applicable Elements) Appeals 30 27 27 0 3 100% Grievances 12 8 8 0 4 100% Totals 42 35 35 0 7 100% *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
Table 1-3 presents the scores for ABC-NE for each of the standards. Findings for requirements receiving a score of Met are summarized in this section. Details of the findings for each requirement receiving a score of Partially Met or Not Met follow in Appendix A—Compliance Monitoring Tool.
Table 1-3—Summary of ABC-NE Scores for the Standards # of # Score # of Applicable # Partially # Not # Not (% of Met Standards Elements Elements Met Met Met Applicable Elements) V. Member Information 12 11 7 4 0 1 64% VI. Grievance System 27 27 23 4 0 0 85% VII. Provider Participation 13 13 12 1 0 0 92% and Program Integrity IX. Subcontracts and 4 4 4 0 0 0 100% Delegation Totals 56 55 46 9 0 1 84% Note: While scoring related to individual, new federal requirements in the tool may indicate Met or Not Scored, all new requirements were scored Not Applicable in the total results; new federal requirements do not apply to CHP+ until July 1, 2018. *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements.
Table 1-4 presents the scores for ABC-NE for the record reviews. Details of the findings for the record reviews are in Appendix B—Record Review Tools.
Table 1-4—Summary of ABC-NE Scores for the Record Reviews # of Score # of Applicable # # Not # Not (% of Met Record Review Elements Elements Met Met Applicable Elements) Appeals 24 21 20 1 3 95% Grievances 42 29 29 0 13 100% Totals 66 50 49 1 16 98% *The overall score is calculated by adding the total number of Met elements and dividing by the total number of applicable elements.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-3 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
Standard V—Member Information
The following sections summarize findings applicable to both ABC-D and ABC-NE. Any notable differences in compliance between the two lines of business have been identified.
Summary of Strengths and Findings as Evidence of Compliance
HSAG reviewed ABC policies and procedure regarding member materials and found them appropriate to meet the requirements and ensure that member communications were accessible. ABC-D and ABC- NE used many of the same member materials across both lines of business and made all member materials available in English and in Spanish. In addition, the ABC website included a translation function which made the website viewable in over 50 languages. ABC is compliant in making member materials available in various, alternate formats and provided an example during the on-site interview where the BHO had converted the entire member handbook into Braille when it was requested. While this was an expensive endeavor, ABC ensured that this specific member had access to information regarding rights and processes for obtaining healthcare.
HSAG found that member materials, both printed and electronic, used simple, easy-to-understand language. ABC arranged its website in a user-friendly format that allows for intuitive use and member ease in finding important information. ABC provides a wealth of information to its members on the website, which serves as a valuable resource.
Summary of Findings Resulting in Opportunities for Improvement
ABC may wish to review all member documents to ensure that the general text of PDF versions of member materials is made available to members in at least a 12-point font. HSAG reviewed various member material available in PDF format; and while the font appeared to be in an acceptable range, HSAG was unable to directly confirm the font size due to the PDF format.
Summary of Required Actions
HSAG found that the taglines describing how to request auxiliary aids and services, including written translation and oral interpretation, while present, were not printed in 18-point font on both paper and in electronic member materials, as required. ABC-D and ABC-NE must ensure that all member materials include taglines describing how to request auxiliary aids and services including written translation and oral interpretation in 18-point font.
During the desk review, HSAG found that ABC provided two member handbooks to members, the Health First Colorado member handbook and ABC’s own member handbook available on its website at the webpage: http://coaccess.com/ABC-denver-plan-documents-and-forms. HSAG noted that the ABC- D handbook contained information which conflicts with the Health First Colorado member handbook, which could be confusing to members. For example, the information ABC-D provided to members in
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-4 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
the Member and Family Handbook had not been updated to reflect current time frames and procedures for grievance, appeals, and State fair hearings (SFHs) in accordance with 42 CFR §438.10 information requirements. During the on-site interview ABC noted that this was unintentional and that the ABC member handbook would be removed immediately. A week following the on-site review, HSAG confirmed that the webpage for ABC-NE contained a link to only the Health First Colorado member handbook; however, HSAG found that the ABC-D Member and Family Handbook had not been removed from the website. ABC-D must remove its Member and Family Handbook from its website to ensure that members are not receiving conflicting or inaccurate information on appeals, grievances, SFHs, or other member information.
During desk review, HSAG was unable to locate notification on the ABC website informing members that electronic information is available in paper form upon request without charge and is provided within five) business days. ABC must inform members on a prominent place of its website that information on the website is available in paper form upon request, without charge, and provided within five business days.
During the desk review process, HSAG conducted an accessibility check on several ABC webpages using the Wave Web Accessibility Evaluation Tool. Through use of the tool, HSAG discovered several general accessibility errors and contrast errors on various webpages. HSAG also ran an accessibility check on several PDF documents available for download from the ABC website. Through use of the Adobe Acrobat Pro accessibility checker, HSAG discovered accessibility errors within these PDF documents. HSAG repeated these accessibility checks during the on-site review for educational purposes and the same outcomes were discovered. ABC must develop a process to ensure that all information on its website is readily accessible (i.e., complies with 508 guidelines, Section 504 of the Rehabilitation Act, and W3C’s Web Content Accessibility Guidelines).
HSAG found that the disability accommodation field in ABC’s “Find A Provider” provider search feature on its website did not define the specific accommodations available at each provider’s location. ABC staff members confirmed that only one area of disability access, such as handicap parking or a nearby public transit line, could qualify a provider as having “disability access.” The requirement, however, clarifies this to include accessible offices, exam rooms, and equipment. To comply with the requirement, ABC must update its provider directory or online “Find A Provider” feature to better clarify what it defines as “disability access.”
Standard VI—Grievance System
The following sections summarize findings applicable to both ABC-D and ABC-NE. Any notable differences in compliance between the two lines of business have been identified.
Summary of Strengths and Findings as Evidence of Compliance
ABC had updated both its Member Grievance Process and Member Appeal Process policies to incorporate new federal and State regulations effective July 1, 2017. Although the written policies stated
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-5 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
an effectiveness date of late October 2017, staff members stated that new procedures were implemented July 1, 2017, which HSAG corroborated through appeal record reviews of processes applied and information provided to members in notices of adverse benefit determinations and appeal resolution letters. Staff stated that ABC would begin using the model letters provided by the Department on November 1, 2017. Staff members also stated that applicable changes in the federal regulations effective July 1, 2017, largely reflected processes already in place and operationally applied in processing of appeals and grievances by Colorado Access. Record reviews for both ABC-D and ABC-NE demonstrated 100 percent compliance with requirements for processing grievances. ABC-D also demonstrated 100 percent compliance with requirements for processing appeals, and ABC-NE demonstrated compliance in all but one record. Staff demonstrated that the appeal manager contacts all members orally (and in writing) to acknowledge receipt of appeals, offer assistance to members, share all available pre- and post-appeal information in the files, and ensure that each member understands his or her appeal resolution. ABC efficiently processes all grievances and appeals, rarely extending the time frame needed to issue a determination and rarely denying the request for an expedited decision. In addition, while ABC attempts to gain a signature from the member on any written appeal following an oral appeal, ABC routinely processes the appeal within the required time frame without a signature if necessary. (HSAG considers this “best practice” in these circumstances.) ABC maintains records of appeals and grievances, including all required information, in the Altruista Health care management system for a period of 10 or more years.
Summary of Findings Resulting in Opportunities for Improvement
HSAG made several on-site recommendations for improvement in ABC policies and procedures, which ABC modified at the time of on-site review. These recommendations included the following:
• Staff members confirmed that the processing of member quality of care concerns (QOCCs) was a component of the member grievance process; however, the Quality of Care Concern Investigations policy did not specify or refer the reader to the time frames for acknowledgement or grievance resolution letters to members. Staff members verbalized the process for handling QOC grievances and that each member would receive within 15 days a grievance resolution letter indicating that the grievance resolution was referred for further QOC review. HSAG recommended that the policy and procedures clearly state that QOC grievances will be processed according to time frames outlined in ADM203—Member Grievance Process and consider instructions for language to be included in the results of the resolution description when the grievance is a QOCC. • HSAG noted that the Member Grievance process policy included a statement—decisions shall take into account all information submitted by a member “without regard to whether such information was submitted or considered in the initial adverse benefit determination.” As the quoted clause applies to appeals but not grievances, HSAG suggested it be deleted from the grievance policy. • HSAG queried staff regarding the process for obtaining a member signature on a written appeal and the processing of an appeal when a signature cannot be obtained. Staff members described a very deliberate outreach process and stated that the BHO would not delay an appeal decision due to inability to obtain a member signature. HSAG suggested that written appeal procedures include a description of this process to ensure that it is followed by all staff.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-6 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
• HSAG observed that Colorado Access informs members of their right to and process for requesting an SFH through both the notice of adverse benefit determination and the appeal resolution notice (if not in favor of the member). The Member Appeal policy stated only that the member is informed about an SFH in the notice of action (NOA). HSAG recommended adding appeal resolution notice language to the policy.
Colorado Access described the language concerning appeals and grievances to be included in the revised provider manual (with an anticipated completion date of early 2018), which would include links to the updated grievance and appeal policies on the provider website. The information included in the provider manual is very general concerning the member’s right to file grievances and appeals and the provider’s participation in doing so. HSAG advises that ABC consider including the essential information to providers, as described in the requirements, directly in the member handbook. In addition, the current provider manual refers providers to a link for the member handbook for information on grievances and appeals. ABC no longer controls the content of the member handbook; therefore, HSAG cautions that directing providers to the member handbook may be an inadequate action to meet requirements for informing providers of grievance and appeal procedures.
Summary of Required Actions
While the Member Grievance Process policy had been updated to indicate that a member may file a grievance at any time, the related policy—Quality of Care Concern (QOCC) Investigations—stated that a member must file a QOCC within 30 days of the incident. ABC must ensure that the QOCC policy is updated to reflect that a quality of care grievance may be filed by a member at any time. Policy revisions must be approved by appropriate governing bodies and implemented, including any applicable staff training.
HSAG noted one ABC-NE appeal record in which the BHO failed to send an acknowledgement letter within two days of receipt of the appeal request. ABC-NE must have mechanisms to ensure that written acknowledgement of a standard appeal request is sent to the member or designated representative, consistent with ABC policies and procedures.
Member Appeal Processes policy accurately addressed all required criteria for the length of time that benefits would continue during an appeal or SFH, but also included an additional criterion—“until the time period or service limits of the previously authorized service has been met.” This circumstance does not apply to the length of time that benefits may continue. ABC must remove this specific criterion in the member appeals policy as well as in any related member or provider communications (e.g., appeal resolution or adverse determination letters). Policy revisions must be approved by appropriate governing bodies and implemented, including any applicable staff training.
The ABC provider manual contained no detailed information to address the required components of the information about the grievance, appeal, and SFH system. The manual directed the provider to two different Colorado Access website locations to find detailed instructions or procedures related to grievances and appeals, but neither website link included detailed procedures for appeals and grievances. In addition, the provider manual included no information on the appeals process available
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-7 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
under the Child Mental Health Treatment Act (CMHTA). Whereas new requirements and time frames for processing grievances and appeals have been in effect since July 1, 2017, ABC must develop accessible and timely mechanisms to inform providers and subcontractors about the grievance, appeal, and SFH system in sufficient detail to address all federal and State requirements for provider information.
Standard VII—Provider Participation and Program Integrity
The following sections summarize findings applicable to both ABC-D and ABC-NE. Any notable differences in compliance between the two lines of business have been identified.
Summary of Strengths and Findings as Evidence of Compliance
ABC’s policy, Member Services Verification Plan, included recently implemented processes for providing individual notices to a sample of members to verify and report whether services billed by providers had actually been received by members.
ABC’s policies for the selection and retention of providers were well written and clearly described methods used to identify a specific area of need and then to recruit providers to fill the gap. HSAG reviewed the template letter related to declining a new provider from participation and found the content appropriate. ABC provided a description of its process, both prior to hiring and monthly ongoing, for ensuring that all providers, employees, board members, consultants, etc., are not excluded from participation in federal healthcare programs. ABC staff members clearly described what would happen in the event that an applicant or current provider, employee, or other relationship was found to be excluded from participation in federal programs. ABC supplied HSAG with reports evidencing that a process for reviewing the LEIE and SAM monthly for current providers, employees, board members, consultants, and the like is in place as described in policies. ABC clearly described that, in the event that an applicant, current provider, employee, or other relationship was found to be excluded from participation in federal programs, the provider contract would be terminated and the appropriate channels, including the Department, notified.
During the on-site review, HSAG and ABC staff members spent considerable time discussing the compliance program, specifically as it relates to ABC’s compliance organizational structure, chain of command, and processes. ABC staff members discussed the in-person compliance training that takes place within ABC upon hire and the e-learning training that occurs annually. The compliance officer also noted the educational programs and professional organizations with which she maintains membership to ensure that she is up-to-date on topics in corporate compliance and fraud, waste, and abuse. ABC thoroughly described its processes for monitoring and reporting fraud, waste, and abuse.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-8 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
Summary of Findings Resulting in Opportunities for Improvement
During the on-site review, the compliance officer discussed a new edition of ABC’s provider manual anticipated to be released in the first half of 2018. ABC is redesigning its manual to be web-based and to link providers directly to policies and procedures as well as other resources. This process will allow ABC to incorporate updates in real time, including up-to-date information on compliance and fraud, waste, and abuse. This will transform the provider manual into a more dynamic tool for provider communication. HSAG recommends that ABC expedite developing the new version of its provider manual.
Summary of Required Actions
HSAG determined that ABC’s policies did include a process for ensuring that laboratory-testing sites have either a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver or a certificate of registration along with a CLIA registration number. During the on-site interview, ABC staff members confirmed that hospital laboratories were used by members but that checking for CLIA certification was not a part of the credentialing process. ABC must ensure that it develops and adheres to a documented process whereby all laboratory-testing sites providing services to ABC members have either a CLIA Certificate of Waiver or a certificate of registration along with a CLIA registration number.
Standard IX—Subcontracts and Delegation
The following sections summarize findings applicable to both ABC-D and ABC-NE. Any notable differences in compliance between the two lines of business have been identified.
Summary of Strengths and Findings as Evidence of Compliance
ABC subcontracts and delegation policies, procedures, and agreements reflect the corporatewide processes of Colorado Access, applicable to all lines of business. No notable differences in compliance existed between ABC-D and ABC-NE. Colorado Access subcontracted with entities for the following services: provider credentialing, claims systems, pharmacy management, after-hours crisis calls, fulfillment of member identification cards, fulfillment of member materials, review of clinical appeals, specialist clinical review, and after-hours utilization management. Policies described the delegation program, accountable to the compliance officer, and addressed Colorado Access’ ultimate accountability for all delegated activities, pre-delegation assessment of the subcontractor, and ongoing oversight and monitoring of delegated functions—with corrective actions and potential revocation of the subcontract if necessary. The subcontractor agreement template and existing subcontractor agreements had been updated to include all information described in the requirements of this standard as well as a detailed description of delegated activities and related reporting requirements. All agreements had been previously executed several years prior to the on-site review. Colorado Access had designated internal “business owners” for oversight of each subcontractor, including ongoing monitoring and management
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-9 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 EXECUTIVE SUMMARY
of corrective actions and provided sample documentation of monthly performance tracking and annual audit of delegate requirements. Monitoring reports were provided monthly to the Colorado Access Quality Assurance Committee. During on-site interviews, staff members indicated that one of Colorado Access’ subcontracts had been revoked during the past year for inability of the subcontractor to adequately perform the delegated functions. The process included collecting and investigating issues brought forward from various sources for validation; termination of the provider when allegations are confirmed; collection and reimbursement of paid funds; and notification of appropriate entities, including the Department.
Summary of Findings Resulting in Opportunities for Improvement
HSAG identified no opportunities for improvement related to subcontracts and delegation.
Summary of Required Actions
HSAG identified no required actions for this standard.
Access Behavioral Care FY 2017–2018 Site Review Report Page 1-10 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 2. Overview and Background
Overview of FY 2017–2018 Compliance Monitoring Activities
For the fiscal year (FY) 2017–2018 site review process, the Department requested a review of four areas of performance. HSAG developed a review strategy and monitoring tools consisting of four standards for reviewing the performance areas chosen. The standards chosen were Standard V—Member Information, Standard VI—Grievance System, Standard VII—Provider Participation and Program Integrity, and Standard IX—Subcontracts and Delegation. Compliance with applicable federal managed care regulations and managed care contract requirements was evaluated through review of all four standards.
Compliance Monitoring Site Review Methodology
In developing the data collection tools and in reviewing documentation related to the four standards, HSAG used the BHO’s contract requirements and regulations specified by federal Medicaid managed care regulations published May 6, 2016. The Department determined that the Health First Colorado member handbook was the source of member handbook information and that BHOs were not accountable for compliance with member handbook federal requirements in 42 CFR 438.10(g). HSAG conducted a desk review of materials submitted prior to the on-site review activities: a review of records, documents, and materials provided on-site; and on-site interviews of key BHO personnel to determine compliance with federal managed care regulations and contract requirements. Documents submitted for the desk review and on-site review consisted of policies and procedures, staff training materials, reports, minutes of key committee meetings, member and provider informational materials, and administrative records related to BHO appeals and grievances.
HSAG also reviewed a sample of the BHO’s administrative records related to Medicaid appeals and grievances to evaluate implementation of federal healthcare regulations and managed care contract requirements as specified in 42 CFR 438 Subpart F and 10 CCR 2505-10, Section 8.209. Reviewers used standardized monitoring tools to review records and document findings. HSAG used a sample of 10 records with an oversample of five records (to the extent that a sufficient number existed) for each of ABC-D and ABC-NE. Using a random sampling technique, HSAG selected the samples from all applicable BHO Medicaid appeals and grievances that occurred between July 1, 2017, and December 31, 2017. For the record review, the BHO received a score of M (met), NM (not met), or NA (not applicable) for each required element. Results of record reviews were considered in the review of applicable requirements in Standard VI—Grievance System. HSAG also separately calculated a grievances record review score, an appeals record review score, and an overall record review score.
The site review processes were consistent with EQR Protocol 1: Assessment of Compliance with Medicaid Managed Care Regulations: A Mandatory Protocol for External Quality Review (EQR),
Access Behavioral Care FY 2017–2018 Site Review Report Page 2-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 OVERVIEW AND BACKGROUND
Version 2.0, September 2012.3-1 Appendix E contains a detailed description of HSAG’s site review activities consistent with those outlined in the CMS final protocol. The four standards chosen for the FY 2017–2018 site reviews represent a portion of the Medicaid managed care requirements. The following standards will be reviewed in subsequent years: Standard I—Coverage and Authorization of Services, Standard II—Access and Availability, Standard III—Coordination and Continuity of Care, Standard IV—Member Rights and Protections, Standard VIII—Credentialing and Recredentialing, and Standard X—Quality Assessment and Performance Improvement.
Objective of the Site Review
The objective of the site review was to provide meaningful information to the Department and the BHO regarding:
• The BHO’s compliance with federal health care regulations and managed care contract requirements in the four areas selected for review. • Strengths, opportunities for improvement, and actions required to bring the BHO into compliance with federal health care regulations and contract requirements in the standard areas reviewed. • The quality and timeliness of, and access to, services furnished by the BHO, as assessed by the specific areas reviewed. • Possible interventions recommended to improve the quality of the BHO’s services related to the standard areas reviewed.
3-1 Department of Health and Human Services, Centers for Medicare & Medicaid Services. EQR Protocol 1: Assessment of Compliance with Medicaid Managed Care Regulations: A Mandatory Protocol for External Quality Review (EQR), Version 2.0, September 2012. Available at: https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed- care/external-quality-review/index.html. Accessed on: Sep 26, 2017
Access Behavioral Care FY 2017–2018 Site Review Report Page 2-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
3. Follow-Up on Prior Year's Corrective Action Plan
FY 2016–2017 Corrective Action Methodology
As a follow-up to the FY 2016–2017 site review, each BHO that received one or more Partially Met or Not Met scores was required to submit a corrective action plan (CAP) to the Department addressing those requirements found not to be fully compliant. If applicable, the BHO was required to describe planned interventions designed to achieve compliance with these requirements, anticipated training and follow-up activities, the timelines associated with the activities, and documents to be sent following completion of the planned interventions. HSAG reviewed the CAP and associated documents submitted by the BHO and determined whether it successfully completed each of the required actions. HSAG and the Department continued to work with ABC-D and ABC-NE until each completed the required actions from the FY 2016–2017 compliance monitoring site review.
Summary of FY 2016–2017 Required Actions
For the FY 2016–2017, HSAG reviewed Standard I—Coverage and Authorization of Services and Standard II—Access and Availability. HSAG found ABC-D and ABC-NE 100 percent compliant with the requirements in the access and availability standard. Both ABC-D and ABC-NE were required to develop plans to address the following issues related to coverage and authorization of services:
• Effective mechanisms to ensure that all information in NOAs to members is appropriate to the members and written in language that ensures ease of understanding and that NOAs are mailed in the required time frames, as outlined in the policies and procedures • A process to ensure that both the UM procedures and claims payment decisions are linked to the requirements for the Contractor’s financial responsibilities for post-stabilization care services not pre-approved, as outlined in the Emergency and Post-Stabilization Care policy. • A process to ensure that the Contractor’s financial responsibilities for post-stabilization care services not pre-approved, as outlined in the Emergency and Post-Stabilization Care policy, are integrated into claims payment decisions.
Additionally, ABC-NE was required to implement a mechanism to ensure that it gives the member written notice of any decision to deny a service authorization request.
Summary of Corrective Action/Document Review
ABC-D and ABC-NE submitted a proposed plan of corrective actions in May 2017. After reviewing the proposed plan, HSAG and the Department required that ABC-D and ABC-NE revise two proposed interventions. ABC-D and ABC-NE were allowed until December 30, 2017, to submit evidence of having implemented corrective actions. HSAG completed this 2017–2018 compliance monitoring report
Access Behavioral Care FY 2017–2018 Site Review Report Page 3-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 FOLLOW-UP ON PRIOR YEAR'S CORRECTIVE ACTION PLAN
prior to receiving and processing ABC-D’s and ABC-NE’s 2016–2017 CAP submission and is unable to comment on the completeness of the corrective actions.
Summary of Continued Required Actions
HSAG will review ABC-D’s and ABC-NE’s CAP submission with the Department when received and work with the BHOs to ensure full implementation of all corrective actions.
Access Behavioral Care FY 2017–2018 Site Review Report Page 3-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
Appendix A. Compliance Monitoring Tool
The completed compliance monitoring tool follows this cover page.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 1. The Contractor provides all required member • ADM208 Member Materials ABC-D information to members in a manner and format that • ADM 207 Effective Communication with LEP & SI/SI Met may be easily understood and is readily accessible Persons Partially Met by members. Not Met • MKT203 Website Design, Maintenance and Oversight N/A (Note: Readily accessible means electronic • MKT201 Printing/Marketing Information and Corporate information which complies with 508 guidelines, Branding Materials ABC-NE Section 504 of the Rehabilitation Act, and W3C’s • Language selection on Colorado Access Website Met Web Content Accessibility Guidelines.) http://www.coaccess.com/access-behavioral-care Partially Met 42 CFR 438.10(b)(1) Not Met N/A Contract Amendment 7: Exhibit A3—2.6.5.13.1
2. For consistency in the information provided to ABC-D members, the Contractor uses the following as Met developed by the State: Partially Met • Definitions for managed care terminology, Not Met including appeal, co-payment, durable N/A medical equipment, emergency medical condition, emergency medical transportation, ABC-NE emergency room care, emergency services, Met excluded services, grievance, habilitation services and devices, health insurance, home Partially Met health care, hospice services, hospitalization, Not Met hospital outpatient care, medically necessary, N/A network, non-participating provider, physician services, plan, preauthorization, participating provider, premium, prescription drug coverage, prescription drugs, primary care physician, primary care provider,
Access Behavioral Care FY 2017–2018 Site Review Report Page A-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score provider, rehabilitation services and devices, skilled nursing care, specialist, and urgent care. • Model member handbooks and member notices.
42 CFR 438.10(c)(4)
Contract Amendment 7: Exhibit A3—2.2.6, 2.3.2, 3.1.7 Findings: HSAG is aware and the Department acknowledges that, for the 2017–2018 compliance review period, the State has not completed nor communicated to health plan contractors a consensus list of managed care definitions to be used in information provided to members. HSAG has therefore scored this element Not Applicable. HSAG recommends that all Contractors maintain awareness of this requirement and, when received, incorporate State-defined managed care definitions into all applicable member communications, as directed by the Department. 3. The Contractor makes written information available • ADM208 Member Material ABC-D in prevalent non-English languages in its service area • MKT201 Printed Marketing/Informational and Corporate Met and in alternative formats upon member request at no Branding Materials Partially Met cost. • ADM207 Effective Communication with Limited English Not Met • Written materials that are critical to Proficient Persons and SI/SI Persons N/A obtaining services include: provider • Language selection on Colorado Access Website directories, member handbooks, appeal and ABC-NE grievance notices, and denial and termination http://www.coaccess.com/access-behavioral-care Met notices. Partially Met • All written materials for members must: Not Met ̶ Use easily understood language and format. N/A ̶ Use a font size no smaller than 12 point. ̶ Be available in alternative formats and through provision of auxiliary aids and
Access Behavioral Care FY 2017–2018 Site Review Report Page A-3 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score services that take into consideration the special needs of members with disabilities or limited English proficiency. ̶ Include taglines in large print (18 point) and prevalent non-English languages describing how to request auxiliary aids and services, including written translation or oral interpretation and the toll-free and TTY/TDY customer service number, and availability of materials in alternative formats. ̶ Be available for immediate dissemination in that language.
42 CFR 438.10(d)(3) and (d)(6)
Contract Amendment 7: Exhibit A3—2.6.5.13.1–3, 2.6.5.13.6.1–3, 2.6.5.13.7, 2.6.5.13.10.1–4 Findings: HSAG found that the taglines describing how to request auxiliary aids and services including written translation and oral interpretation, while present, were not in 18-point font on either paper or electronic member materials, as required. Required Actions: ABC-D and ABC-NE must ensure that all member materials include taglines describing how to request auxiliary aids and services including written translation and oral interpretation in 18-point font.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-4 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 4. If the Contractor makes information available • MKT203 Website Design, Maintenance and Oversight ABC-D electronically—Information provided Met • ADM207 Effective Communication with Limited English electronically must meet the following Partially Met requirements: Proficient Persons and SI/SI Persons Not Met
• The format is readily accessible (see definition N/A of readily accessible above). • The information is placed in a Web site ABC-NE location that is prominent and readily Met accessible. Partially Met • The information can be electronically retained Not Met and printed. N/A • The information complies with content and language requirements. • The member is informed that the information is available in paper form without charge upon request, and is provided within five (5) business days.
42 CFR 438.10(c)(6)
Contract Amendment 7: Exhibit A3—2.6.5.3.6–8 Findings: During the desk review process, HSAG conducted an accessibility check on a few ABC Web pages using the WAVE Web Accessibility Evaluation Tool. Through use of the tool, HSAG discovered several general accessibility errors and contrast errors on various Web pages. HSAG also ran an accessibility check on several PDF documents available for download from the ABC website. Through use of the Adobe Acrobat Pro accessibility checker, HSAG discovered accessibility errors. HSAG repeated these accessibility checks during the on-site review for educational purposes, and the same outcomes were discovered.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-5 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score HSAG was unable to locate notification on the ABC website informing members that electronic information is available in paper form upon request without charge and is provided within five business days. During the on-site interview, HSAG and ABC discussed possible placement on the website appropriate for displaying such messaging, especially considering that many members may not have state-of-the-art cell phones or access to sufficient bandwidth to search the website for this notice or to download the available PDF documents. Required Actions: ABC must develop a process to ensure that all information on its website is readily accessible (i.e., complies with 508 guidelines, Section 504 of the Rehabilitation Act, and W3C’s Web Content Accessibility Guidelines). ABC must inform members in a prominent place of its website that information on the website is available in paper form upon request without charge, and provided within five business days. 5. The Contractor makes interpretation services (for all • ADM207 Effective Communication with Limited English ABC-D non-English languages) available free of charge and Proficient Persons and SI/SI Persons Met notifies members that oral interpretation is available • COA Provider Manual, Page 3-4, 9 Partially Met for any language and written translation is available Not Met in prevalent languages, and how to access them. N/A • This includes oral interpretation and use of auxiliary aids such as TTY/TDY and ABC-NE American Sign Language. Met • The Contractor notifies members that auxiliary Partially Met aids and services are available upon request Not Met and at no cost for members with disabilities, N/A and how to access them.
42 CFR 438.10(d)(4) and (d)(5)
Contract Amendment 7: Exhibit A3—2.6.5.13.7–9 Findings: On its website, ABC included a function to decipher its webpages (not including PDF documents) into any one of over 50 languages. ABC did not, however, include directly on its website or within the associated PDF member materials notification to the member that oral interpretation in any language, as well as other auxiliary aids, are available free of charge or how members may access them.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-6 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score Required Actions: While ABC does provide oral interpretation, and use of auxiliary aids to members free of charge as needed, ABC must notify members that these provisions are available and how to access them. During the on-site review, HSAG and ABC discussed prominent places for disseminating this information on the ABC website. 6. The Contractor makes a good faith effort to give • ADM300 Provider Terminations ABC-D written notice of termination of a contracted provider Met within 15 days after the receipt or issuance of the Partially Met termination notice, to each member who received his Not Met or her primary care from or was seen on a regular N/A basis by the terminated provider.
42 CFR 438.10(f)(1) ABC-NE Met Contract Amendment 7: Exhibit A3—2.6.10.1 Partially Met Not Met N/A
7. The Contractor makes available to members in paper • COA Website ABC-D or electronic form the following information about https://providers.coaccess.com/ProviderSearch/home.jsf Met contracted network physicians (including Partially Met specialists), hospitals, pharmacies, and behavioral Not Met health providers, and long-term services and N/A supports (LTSS) providers:
• The provider’s name and group affiliation, ABC-NE street address(es), telephone number(s), Web Met site URL, specialty (as appropriate), and whether the providers will accept new members. Partially Met Not Met • The provider’s cultural and linguistic N/A capabilities, including languages (including
Access Behavioral Care FY 2017–2018 Site Review Report Page A-7 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score American Sign Language) offered by the provider or provider’s office, and whether the provider has completed cultural competency training. • Whether the provider’s office has accommodations for people with physical disabilities, including offices, exam rooms, and equipment.
(Note: Information included in a paper provider directory must be updated at least monthly, and electronic provider directories must be updated no later than 30 calendar days after the Contractor receives updated provider information.)
42 CFR 438.10(h)(1-3)
Contract Amendment 7: Exhibit A3—2.6.5.8.1–3 Findings: HSAG reviewed both the provider directory and the “Find A Provider” feature on the ABC website. While the provider directory did not contain all required information, the “Find A Provider” was a valuable resource that contained comprehensive information in a searchable format. As discussed on-site, the disability accommodation field did not define the accommodations available at each provider’s location. Further research performed by ABC during the on-site visit concluded that only one area of disability access, such as handicap parking or a nearby public transit line, could qualify a provider as having “disability access.” The requirement, however, clarifies this to include accessible offices, exam rooms, and equipment. Required Actions: ABC must update its provider directory or online “Find A Provider” feature to better clarify what it defines as “disability access,” in agreement with the requirement.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-8 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 8. Provider directories are made available on the • COA Website: ABC-D Contractor’s Web site in a machine-readable file https://providers.coaccess.com/ProviderSearch/home.jsf Met and format. • MKT203 Website Design, Maintenance and Oversight Partially Met Not Met 42 CFR 438.10(h)(4) N/A
Contract Amendment 7: Exhibit A3—2.6.5.8.4 ABC-NE Met Partially Met Not Met N/A
9. The Contractor provides other necessary information • Health First Colorado Member handbook ABC-D to members, including: https://www.healthfirstcolorado.com/benefits-services/ Met • The Child Mental Health Treatment Act Partially Met (CMHTA). • Colorado Access Website Not Met • Community resources. http://www.coaccess.com/find-a-community-resource N/A
Contract Amendment 7: Exhibit A3—2.6.7.3.1 and 2.6.7.3.3 ABC-NE Met Partially Met Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-9 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 10. For any information provided to members by the • ADM208 Member Materials ABC-D Contractor, the Contractor ensures that information is Met consistent with federal requirements in 42 CFR Partially Met 438.10. Not Met
N/A 42 CFR 438.10 (b)
ABC-NE Met Partially Met Not Met N/A
Findings: During the desk review, HSAG found that ABC had two member handbooks, the Health First Colorado member handbook and its own member handbook, on its website at the webpage coaccess.com/abc-denver-plan-documents-and-forms. During the on-site interview, ABC noted that this was unintentional and that it would be removed immediately. A week following the on-site review, the ABC-D Member and Family Handbook had not been removed. HSAG found that the ABC-D handbook contained information which conflicts with the Health First Colorado member handbook, which could be confusing to members. For example, the information ABC-D provided to members in the Member and Family Handbook had not been updated to reflect current time frames and procedures for grievances and appeals in accordance with 42 CFR §438.10 information requirements. HSAG viewed a similar webpage for ABC-NE, which contained only a link to the Health First Colorado member handbook. Required Actions: ABC-D must remove its Member and Family Handbook from its webpage to ensure that members are not receiving conflicting or inaccurate information about appeals and grievances.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-10 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 11. The Contractor provides member information by • ADM207 Effective Communication with LEP & SI/SI ABC-D any of: Persons Met • Mailing a printed copy of the information to • ABCD_ABCNE FY17 Annual Communications Plan Partially Met the member’s mailing address. Not Met • Providing the information by email after N/A obtaining the member’s agreement to receive the information by email. ABC-NE • Posting the information on the Contractor’s Met Web site and advising the member in paper or Partially Met electronic form that the information is Not Met available on the Internet and including the N/A applicable Internet address, provided that members with disabilities who cannot access this information online are provided auxiliary aids and services upon request at no cost. • Providing the information by any other method that can reasonably be expected to result in the member receiving that information. 42 CFR 438.10(g)(3)
Access Behavioral Care FY 2017–2018 Site Review Report Page A-11 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard V—Member Information Requirement Evidence as Submitted by the BHO Score 12. The Contractor must make available to members, • ABC309 Physician Incentive Plans ABC-D upon request, any physician incentive plans in place. • CS DP24 Physician Incentive Plans Met Partially Met 42. FR 438.10(f)(3) Not Met N/A
ABC-NE Met Partially Met Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-12 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Results for Standard V—Member Information for ABC-D Total Met = 6 X 1.00 = 6 Partially Met = 5 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 1 X NA = NA Total Applicable = 11 Total Score = 6
Total Score ÷ Total Applicable = 55%
Results for Standard V—Member Information for ABC-NE Total Met = 7 X 1.00 = 7 Partially Met = 4 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 1 X NA = NA Total Applicable = 11 Total Score = 7
Total Score ÷ Total Applicable = 64%
Access Behavioral Care FY 2017–2018 Site Review Report Page A-13 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 1. The Contractor has established internal grievance • ADM203 Member Grievance Process ABC-D procedures under which members, or providers acting on • ADM219 Member Appeal Process Met their behalf, may challenge the denial of coverage of, or • QM201 Investigation of Potential Clinical Partially Met payment for, medical assistance. The contractor must have Quality of Care Grievances and Referrals Not Met a grievance and appeal system in place to handle appeals of N/A an adverse benefit determination and grievances, as well as processes to collect and track information about them. ABC-NE • The Contractor may have only one level of appeal for Met members (or providers acting on their behalf). Partially Met • A member may request a State fair hearing after Not Met receiving an appeal resolution notice from the N/A Contractor that the adverse benefit determination has
been upheld. • If the Contractor fails to adhere to required time frames for processing appeals, the member is deemed to have exhausted the Contractor’s appeal process and the member may initiate a State fair hearing.
42 CFR 438.400(a)(3) 42 CFR 438.402(a-c) 42 CFR 438.400(b)
Contract Amendment 7: Exhibit A3—2.6.4.1, 2.6.4.9.1, 2.6.4.9.3 10 CCR 2505-10—8.209.3.A, 8.209.4.A.2.c, 8.208.4.N, and 8.209.4.O
Access Behavioral Care FY 2017–2018 Site Review Report Page A-14 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 2. The Contractor defines “adverse benefit determination” as: • CCS307 Utilization Review Determinations ABC-D • The denial or limited authorization of a requested service, • ADM219 Member Appeal Process Met including determinations based on the type or level of Partially Met service, requirements for medical necessity, Not Met appropriateness, setting, or effectiveness of a covered N/A benefit. • The reduction, suspension, or termination of a previously ABC-NE authorized service. Met • The denial, in whole, or in part, of payment for a service. Partially Met • The failure to provide services in a timely manner, as Not Met defined by the State. N/A • The failure to act within the time frames defined by the State for standard resolution of grievances and appeals. • The denial of a member’s request to dispute a member financial liability (cost-sharing, copayments, premiums, deductibles, coinsurance, or other). • For a resident of a rural area with only one managed care plan, the denial of a Medicaid member’s request to exercise his or her rights to obtain services outside of the network under the following circumstances: ̶ The service or type of provider (in terms of training, expertise, and specialization) is not available within the network. ̶ The provider is not part of the network but is the main source of a service to the member—provided that: o The provider is given the opportunity to become a participating provider.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-15 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score o If the provider does not choose to join the network or does not meet the Contractor’s qualification requirements, the member will be given the opportunity to choose a participating provider and then will be transitioned to a participating provider within 60 days.
42 CFR 438.400(b) 42 CFR 438.52(b)(2)(ii) Contract Amendment 7: Exhibit A3—1.1.1.3 10 CCR 2505-10—8.209.2.A 3. The Contractor defines “Appeal” as “a review by the • ADM219 Member Appeal Process ABC-D Contractor of an adverse benefit determination.” Met Partially Met 42 CFR 438.400(b) Contract Amendment 7: Exhibit A3—1.1.1.4 Not Met 10 CCR 2505-10—8.209.2.B N/A
ABC-NE Met Partially Met Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-16 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 4. The Contractor defines “grievance” as “an expression of • ADM203 Member Grievance Process ABC-D dissatisfaction about any matter other than an adverse benefit Met determination.” Partially Met Grievances may include, but are not limited to, the quality of Not Met care or services provided and aspects of interpersonal N/A relationships such as rudeness of a provider or employee or failure to respect the member’s rights regardless of whether ABC-NE remedial action is requested. Grievance includes a member’s right to dispute an extension of time proposed by Met the Contractor to make an authorization decision. Partially Met Not Met
N/A 42 CFR 438.400(b)
Contract Amendment 7: Exhibit A3—1.1.1.27, 2.6.4.5.8.1.2 10 CCR 2505-10—8.209.2.D, 8.209.4.A.3.c.i 5. The Contractor has provisions for who may file: • ADM203 Member Grievance Process ABC-D • A member may file a grievance or a Contractor-level • ADM219 Member Appeal Process Met appeal and may request a State fair hearing. Partially Met
• With the member’s written consent, a provider or Not Met authorized representative may file a grievance or a N/A Contractor-level appeal and may request a State fair hearing on behalf of a member. ABC-NE Met 42 CFR 438.402(c) Partially Met Contract Amendment 7: Exhibit A3—2.6.4.4.1, 2.6.4.4.4, Not Met 2.6.4.6.3, 1.1.1.17 N/A 10 CCR 2505-10—8.209.3.B.1, 8.209.3.B.2, 8.209.2.C
Access Behavioral Care FY 2017–2018 Site Review Report Page A-17 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 6. The Contractor accepts grievances orally or in writing. • ADM203 Member Grievance Process ABC-D Met 42 CFR 438.402(c)(3)(i) Partially Met Contract Amendment 7: Exhibit A3—2.6.4.5.3 10 CCR 2505-10—8.209.5.D Not Met N/A
ABC-NE Met Partially Met Not Met N/A
7. Members may file a grievance at any time. • ADM203 Member Grievance Process ABC-D Met 42 CFR 438.402(c)(2)(i) Partially Met Contract Amendment 7: Exhibit A3—2.6.4.5.3 Not Met 10 CCR 2505-10—8.209.5.A N/A
ABC-NE Met Partially Met Not Met N/A
Findings: The policy ADM203—Member Grievance Process stated that a member may file a grievance at any time. However, the related policy, QM201—Quality of Care Concern (QOCC) Investigations stated that a member may file a quality of care grievance within 30 days of the incident. Staff members stated that the standard operating procedure has always been to accept a member grievance of any nature at any time. During on-site review, staff members corrected the QOCC policy to comply with requirements and correlate with the member grievance policy.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-18 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score However, the revised policy was not effective during the review period; and ABC cannot be credited with this revision pending approval, implementation, and any applicable staff training. Required Actions: ABC must ensure that the QOCC policy is updated to reflect that a quality of care grievance may be filed by a member at any time. Policy revisions must be approved by appropriate governing bodies and implemented, including any applicable staff training. 8. The Contractor sends the member written acknowledgement of • ADM203 Member Grievance Process ABC-D each grievance within two (2) working days of receipt. Met
Partially Met 42 CFR 438.406(b)(1) Not Met Contract Amendment 7: Exhibit A3—2.6.4.5.3 N/A 10 CCR 2505-10—8.209.5.B ABC-NE Met Partially Met Not Met N/A
9. The Contractor must resolve each grievance and provide notice • ADM203 Member Grievance Process ABC-D as expeditiously as the member’s health condition requires, and • ADM208 Member Materials Met within 15 working days of when the member files the Partially Met grievance. Not Met • Notice to the member must be in writing in the format N/A established by the Department. • Notice to the member must be in a format and ABC-NE language that may be easily understood by the Met member. Partially Met
42 CFR 438.408(a) and (b)(1) and (d)(1) Not Met
Contract Amendment 7: Exhibit A3—2.6.4.5.5, 2.6.4.5.5.1, 2.6.5.13.1 N/A 10 CCR 2505-10—8.209.5.D.1, 8.209.5.F
Access Behavioral Care FY 2017–2018 Site Review Report Page A-19 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 10. The written notice of grievance resolution includes: • ADM203- Member Grievance Process ABC-D • Results of the disposition/resolution process and the date it Met was completed. Partially Met Not Met Contract Amendment 7: Exhibit A3—2.6.4.5.5.2 N/A 10 CCR 2505-10—8.209.5.G ABC-NE Met Partially Met Not Met N/A
11. In handling grievances and appeals, the Contractor must give • ADM203 Member Grievance Process ABC-D members reasonable assistance in completing any forms and • ADM219 Member Appeal Process Met taking other procedural steps related to a grievance or appeal. • ADM207 Effective Communication with Partially Met This includes, but is not limited to, auxiliary aids and services limited English proficient persons and SI/SI Not Met upon request, as well as providing interpreter services and Persons toll-free numbers that have adequate TTY/TTD and interpreter N/A capability. ABC-NE 42 CFR 438.406(a)(1) Met Contract Amendment 7: Exhibit A3—2.6.4.3 Partially Met 10 CCR 2505-10—8.209.4.C Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-20 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 12. The Contractor ensures that the individuals who make • ADM219 Member Appeal Process ABC-D decisions on grievances and appeals are individuals who: • ADM203 Member Grievance Process Met • Were not involved in any previous level of review or Partially Met decision-making, nor a subordinate of any such individual. Not Met • Have the appropriate clinical expertise, as determined by N/A the State, in treating the member’s condition or disease if deciding any of the following: ABC-NE ̶ An appeal of a denial that is based on lack of medical Met necessity. Partially Met ̶ A grievance regarding the denial of expedited Not Met resolution of an appeal. N/A ̶ A grievance or appeal that involves clinical issues. • Take into account all comments, documents, records, and other information submitted by the member or their representative without regard to whether such information was submitted or considered in the initial adverse benefit determination.
42 CFR 438.406(b)(2)
Contract Amendment 7: Exhibit A3—2.6.4.5.4, 2.6.4.6.10, 2.6.4.6.6.1, 2.6.4.7.1.1, 2.6.4.7.1.2 10 CCR 2505-10—8.209.5.C, 8.209.4.E
Access Behavioral Care FY 2017–2018 Site Review Report Page A-21 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 13. A member may file an appeal with the Contractor within 60 • ADM219 Member Appeal Process ABC-D calendar days from the date on the adverse benefit Met determination notice. Partially Met
42 CFR 438.402(c)(2)(ii) Not Met N/A Contract Amendment 7: Exhibit A3—2.6.4.6.3.1 10 CCR 2505-10—8.209.4.B ABC-NE Met Partially Met Not Met N/A
14. The member may file an appeal either orally or in writing and • ADM219 Member Appeal Process ABC-D must follow the oral request with a written, signed appeal Met (unless the request is for expedited resolution). Partially Met 42 CFR 438.402(c)(3)(ii) Not Met 42 CFR 438.406(b)(3) N/A
Contract Amendment 7: Exhibit A3—2.6.4.6.3.2 ABC-NE 10 CCR 2505-10—8.209.4.F Met Partially Met Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-22 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 15. The Contractor sends the member written acknowledgement of • ADM219 Member Appeal Process ABC-D each appeal within two (2) working days of receipt, unless the Met member or designated client representative requests an Partially Met expedited resolution. Not Met
42 CFR 438.406(b)(1) N/A
Contract Amendment 7: Exhibit A3—2.6.4.1 ABC-NE 10 CCR 2505-10—8.209.4.D Met Partially Met Not Met N/A
Findings: Appeal policies and procedures accurately addressed written acknowledgement of appeals—unless expedited—within two working days. This was demonstrated in 100 percent of ABC-D record reviews. However, HSAG noted one ABC-NE appeal record which failed to send an acknowledgement letter within two days of receipt of the appeal request. Required Actions: ABC-NE must have mechanisms to ensure that written acknowledgement of a standard appeal request is sent to the member or designated representative, consistent with ABC policies and procedures.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-23 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 16. The Contractor’s appeal process must provide: • ADM219 Member Appeal Process ABC-D • That oral inquiries seeking to appeal an adverse benefit Met determination are treated as appeals (to establish the Partially Met earliest possible filing date), and must be confirmed in Not Met writing unless the member or provider requests expedited N/A resolution. • That if the member orally requests an expedited appeal, the ABC-NE Contractor shall not require a written, signed appeal Met following the oral request. Partially Met • The member a reasonable opportunity, in person and in Not Met writing, to present evidence and testimony and make legal N/A and factual arguments. (The Contractor must inform the member of the limited time available for this sufficiently in advance of the resolution time frame in the case of expedited resolution.) • The member and his or her representative the member’s case file, including medical records, other documents and records, and any new or additional documents considered, relied upon, or generated by the Contractor in connection with the appeal. This information must be provided free of charge and sufficiently in advance of the appeal resolution time frame. • That included, as parties to the appeal, are: ̶ The member and his or her representative. ̶ The legal representative of a deceased member’s estate.
42 CFR 438.406(b)(3-5)
Access Behavioral Care FY 2017–2018 Site Review Report Page A-24 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score Contract Amendment 7: Exhibit A3—2.6.4.6.4, 2.6.4.6.5, 2.6.4.6.7, 2.6.4.6.8, 2.6.4.6.9 10 CCR 2505-10—8.209.4.F, 8.209.4.G, 8.209.4.H, 8.209.4.I
17. The Contractor must resolve each appeal and provide written • ADM219 Member Appeal Process ABC-D notice of the disposition as expeditiously as the member’s Met health condition requires, but not to exceed the following time Partially Met frames: Not Met • For standard resolution of appeals, within 10 working days N/A from the day the Contractor receives the appeal. Note: If the written appeal is not signed by the member or ABC-NE designated client representative (DCR), the appeal Met resolution will remain pending until the appeal is signed. All attempts to gain a signature shall be included in the Partially Met record of the appeal. Not Met N/A • For expedited resolution of an appeal and notice to affected
parties, within 72 hours after the Contractor receives the appeal. • For notice of an expedited resolution, the Contractor must also make reasonable efforts to provide oral notice of resolution. • Written notice of appeal resolution must be in a format and language that may be easily understood by the member.
42 CFR 438.408(b)(2)&(3)&(d)(2) 42 CFR 438.10
Contract Amendment 7: Exhibit A3—2.6.4.7.1, 2.6.4.7.3.2, 2.6.4.7.3.5, 2.6.5.13.1 10 CCR 2505-10—8.209.4.J, 8.209.4.L
Access Behavioral Care FY 2017–2018 Site Review Report Page A-25 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 18. The contractor may extend the time frames for resolution of • ADM203 Member Grievance Process ABC-D grievances or appeals (both expedited and standard) by up to • ADM219 Member Appeal Process Met 14 calendar days: Partially Met • If the member requests the extension; or Not Met • If the Contractor shows (to the satisfaction of the N/A Department, upon request) that there is need for additional information and how the delay is in the member’s interest. ABC-NE • If the Contractor extends the time frames, it must—for any Met extension not requested by the member: Partially Met ̶ Make reasonable efforts to give the member prompt Not Met oral noice of the delay. N/A ̶ Within two (2) calendar days, give the member written notice of the reason for the delay and inform the member of the right to file a grievance if he or she disagrees with that decision. ̶ Resolve the appeal as expeditiously as the member’s health condition requires and no later than the date that the extension expires. • If the Contractor fails to adhere to the notice and timing requirements for extension of the appeal resoultion time frame, the member may initiate a State fair hearing.
42 CFR 438.408(c)
Contract Amendment 7: Exhibit A3—2.6.4.7.2, 2.6.4.7.2.1, 2.6.4.7.8, 2.6.4.7.3.3, 2.6.4.5.8.1.2, 2.6.4.9.3, 2.6.4.6.2.5.2.3 10 CCR 2505-10—8.209.4.J, 8.209.4.O
Access Behavioral Care FY 2017–2018 Site Review Report Page A-26 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 19. The written notice of appeal resolution must include: • ADM219 Member Appeal Process ABC-D • The results of the resolution process and the date it was Met completed. Partially Met • For appeals not resolved wholly in favor of the member: Not Met ̶ The right to request a State fair hearing, and how to do N/A so. ̶ The right to request that benefits/services continue* ABC-NE while the hearing is pending, and how to make the Met request. Partially Met Not Met o That the member may be held liable for the cost of these benefits if the hearing decision upholds the N/A Contractor’s adverse benefit determination.
*Continuation of benefits applies only to previously authorized services for which the Contractor provides 10-day advance notice to terminate, suspend, or reduce. 42 CFR 438.408(e)
Contract Amendment 7: Exhibit A3—2.6.4.7.4, 2.6.4.7.5 10 CCR 2505-10—8.209.4.M
Access Behavioral Care FY 2017–2018 Site Review Report Page A-27 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 20. The member may request a State fair hearing after • ADM219 Member Appeal Process ABC-D receiving notice that the Contractor is upholding the Met adverse benefit determination. The member may request a Partially Met State fair hearing within 120 calendar days from the date Not Met of the notice of resolution. N/A • If the Contractor does not adhere to the notice and timing requirements regarding a member’s appeal, the member is ABC-NE deemed to have exhausted the appeal process and may request a State fair hearing. Met Partially Met • The parties to the State fair hearing include the Contractor as well as the member and his or her representative or the Not Met representative of a deceased member’s estate. N/A
• The Contractor shall participate in all State fair hearings regarding appeals.
42 CFR 438.408(f)(1) and (2) and (3)
Contract Amendment 7: Exhibit A3—2.6.4.9.1, 2.6.4.9.3, 2.6.4.9.2, 2.6.4.9.5 10 CCR 2505-10—8.209.4.N, 8.209.4.O, 8.209.4.H
Access Behavioral Care FY 2017–2018 Site Review Report Page A-28 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 21. The Contractor maintains an expedited review process for • ADM219 Member Appeal Process ABC-D appeals for when the Contractor determines or the provider Met indicates that taking the time for a standard resolution could Partially Met seriously jeopardize the member’s life; physical or mental Not Met health; or ability to attain, maintain, or regain maximum function. The Contractor’s expedited review process includes N/A that: ABC-NE • The Contractor ensures that punitive action is not taken against a provider who requests an expedited resolution or Met supports a member’s appeal. Partially Met • If the Contractor denies a request for expedited resolution Not Met of an appeal, it must: N/A
̶ Transfer the appeal to the time frame for standard resolution. ̶ Make reasonable efforts to give the member prompt oral notice of the denial to expedite the resolution and within two (2) calendar days provide the member written notice of the reason for the decision and inform the member of the right to file a grievance if he or she disagrees with that decision.
42 CFR 438.410
Contract Amendment 7: Exhibit A3—2.6.4.7.3, 2.6.4.7.3.1, 2.10.17.2 10 CCR 2505-10—8.209.4.Q, 8.209.4.R, 8.29.4.S
Access Behavioral Care FY 2017–2018 Site Review Report Page A-29 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 22. The Contractor provides for continuation of benefits/services • ADM219 Member Appeal Process ABC-D while the Contractor-level appeal and the State fair hearing are Met pending if: Partially Met • The member files timely* for continuation of benefits— Not Met defined as on or before the later of the following: N/A ̶ Within 10 days of the Contractor mailing the notice of adverse benefit determination. ABC-NE ̶ The intended effective date of the proposed adverse Met benefit determination. Partially Met • The appeal involves the termination, suspension, or Not Met reduction of a previously authorized course of treatment. N/A • The services were ordered by an authorized provider. • The original period covered by the original authorization has not expired. • The member requests an appeal within 60 calendar days of the notice of adverse benefit determination.
*This definition of “timely filing” only applies for this scenario–i.e., when the member requests continuation of benefits for previously authorized services proposed to be terminated, suspended, or reduced. (Note: The provider may not request continuation of benefits on behalf of the member.)
42 CFR 438.420(a) and (b)
Contract Amendment 7: Exhibit A3—2.6.4.8.1 10 CCR 2505-10—8.209.4.T
Access Behavioral Care FY 2017–2018 Site Review Report Page A-30 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 23. If, at the member’s request, the Contractor continues or • ADM219 Member Appeal Process ABC-D reinstates the benefits while the appeal or State fair hearing is Met pending, the benefits must be continued until one of the Partially Met following occurs: Not Met • The member withdraws the appeal or request for a State N/A fair hearing. • The member fails to request a State fair hearing and ABC-NE continuation of benefits within 10 calendar days after the Met Contractor sends the notice of an adverse resolution to the Partially Met member’s appeal. Not Met • A State fair hearing officer issues a hearing decision N/A adverse to the member.
42 CFR 438.420(c) Contract Amendment 7: Exhibit A3—2.6.4.8.2 10 CCR 2505-10—8.209.4.U Findings: The policy ADM 219—Member Appeal Processes addressed all bullets outlined in the requirement. However, the policy also included an additional criterion: until “the time period or service limits of the previously authorized service has been met.” This criterion is not applicable to the length of time that benefits will be continued. During on-site review, staff members corrected the applicable language in the policy to comply with requirements. However, the revised policy was not effective during the review period; and ABC cannot be credited with this revision pending approval, implementation, and any applicable staff training. Required Actions: ABC must remove inaccurate statements as noted in the member appeals policy as well as any related member or provider communications (e.g., appeal resolution or adverse determination letters). Policy revisions must be approved by appropriate governing bodies and implemented, including any applicable staff training.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-31 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 24. Member responsibility for continued services: • ADM203- Member Grievance Process ABC-D • If the final resolution of the appeal is adverse to the Met member, that is, upholds the Contractor’s adverse benefit Partially Met determination, the Contractor may recover the cost of the Not Met services furnished to the member while the appeal is N/A pending, to the extent that they were furnished solely because of the requirements of this section. ABC-NE Met 42 CFR 438.420(d) Partially Met Contract Amendment 7: Exhibit A3—2.6.4.8.3 Not Met 10 CCR 2505-10—8.209.4.V N/A
25. Effectuation of reversed appeal resolutions: • ADM219 Member Appeal Process ABC-D • If the Contractor or the State fair hearing officer reverses a Met decision to deny, limit, or delay services that were not Partially Met furnished while the appeal was pending, the Contractor Not Met must authorize or provide the disputed services as N/A promptly and as expeditiously as the member’s health condition requires but no later than 72 hours from the date ABC-NE it receives notice reversing the determination. Met • If the Contractor or the State fair hearing officer reverses a Partially Met decision to deny authorization of services and the member Not Met received the disputed services while the appeal was N/A pending, the Contractor must pay for those services, unless State policy and regulations provide for the State to cover the cost of such services.
42 CFR 438.424
Contract Amendment 7: Exhibit A3—2.6.4.8.4, 2.6.4.8.5 10 CCR 2505-10—8.209.4.V, 8.209.W
Access Behavioral Care FY 2017–2018 Site Review Report Page A-32 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 26. The Contractor maintains records of all grievances and appeals. • ADM203 Member Grievance Process ABC-D The records must be accurately maintained in a manner • ADM219 Member Appeal Process Met accessible to the State and available on request to CMS. Partially Met The record of each grievance and appeal must contain, at a Not Met minimum, all of the following information: N/A • A general description of the reason for the grievance or appeal. ABC-NE • The date received. Met • The date of each review or, if applicable, review Partially Met meeting. Not Met • Resolution at each level of the appeal or grievance. N/A • Date of resolution at each level, if applicable. • Name of the person for whom the appeal or grievance was filed.
42 CFR 438.416 Contract Amendment 7: Exhibit A3—2.9.6.2 10 CCR 2505-10—8.209.3.C
Access Behavioral Care FY 2017–2018 Site Review Report Page A-33 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 27. The Contractor provides the information about the grievance • Provider Manual Page 2, 84-85 ABC-D appeal and State fair hearing system to all providers and • PNS201 Provider Manual Directory and Met subcontractors at the time they enter into a contract. The Communication Updates Partially Met information includes: Not Met • The member’s right to file grievances and appeals. N/A • The requirements and time frames for filing grievances and appeals. ABC-NE • The right to a State fair hearing after the Contractor has Met made a decision on an appeal which is adverse to the Partially Met member, including how members obtain a hearing, and the Not Met representation rules at a hearing. N/A • The availability of assistance in the filing processes. • The toll-free number to file orally. • The fact that, when requested by the member: ̶ Services that the Contractor seeks to reduce or terminate will continue if the appeal or request for State fair hearing is filed within the time frames specified for filing. ̶ The member may be required to pay the cost of services furnished while the appeal or State fair hearing is pending, if the final decision is adverse to the member. • Appeals process available under the Child Mental Health Treatment Act (CMHTA), if residential services are denied. • Any State-determined provider’s appeal rights to challenge the failure of the organization to cover a service.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-34 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VI—Grievance System Requirement Evidence as Submitted by the BHO Score 42 CFR 438.414 42 CFR 438.10(g)(xi)
Contract Amendment 7: Exhibit A3—2.6.4.4 10 CCR 2505-10—8.209.3.B Findings: The Colorado Access Professional Provider Agreement incorporates the provider manual by reference. The ABC provider manual included a limited description regarding the member’s right to file grievances and appeals, and included no detailed information to address the required components of the information about the grievance appeal and SFH system. The manual directed the provider to two different Colorado Access website locations to find detailed instructions or procedures related to grievances and appeals. HSAG found that no detailed procedures for appeals or grievances were located at either specified link. In addition, the provider manual included no information on appeals process available under the Child Mental Health Treatment Act (CMHTA). During on-site interviews, staff members stated that the entire provider manual was being rewritten and would be available for publication on or after December 1, 2017. The new provider manual will link the provider to the revised ADM203—Member Grievance Process and ADM219—Member Appeal Process policies on the provider website. Required Action: ABC must develop accessible and timely mechanisms to inform providers and subcontractors about the grievance, appeal, and SFH system in sufficient detail to address all federal and State requirements for provider information.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-35 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Results for Standard VI—Grievance System for ABC-D Total Met = 24 X 1.00 = 24 Partially Met = 3 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 27 Total Score = 24
Total Score ÷ Total Applicable = 89%
Results for Standard VI—Grievance System for ABC-NE Total Met = 23 X 1.00 = 23 Partially Met = 4 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 27 Total Score = 23
Total Score ÷ Total Applicable = 85%
Access Behavioral Care FY 2017–2018 Site Review Report Page A-36 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score 1. The Contractor implements written policies and procedures • PNS202 Selection and Retention of Providers ABC-D for selection and retention of providers. Met
Partially Met 42 CFR 438.214(a) Not Met Contract Amendment 7: Exhibit A3—2.9.7.1.1 N/A
ABC-NE Met Partially Met Not Met N/A
2. The Contractor follows a documented process for • PNS202 Selection and Retention of Providers ABC-D credentialing and recredentialing that complies with the • CR301 Provider Credentialing and Met State’s policies for credentialing. Recredentialing Partially Met • The Contractor uses National Committee for Quality • CR305 Assessment of Organizational Not Met Assurance (NCQA) credentialing and recredentialing Providers N/A standards and guidelines as the uniform and required standards for all contracts. ABC-NE • The Contractor ensures that all laboratory-testing sites Met providing services under the Contract shall have either a Partially Met Clinical Laboratory Improvement Amendments (CLIA) Not Met Certificate of Waiver or a Certificate of Registration along N/A with a CLIA registration number.
42 CFR 438.214(b) and (e)
Contract Amendment 7: Exhibit A3—2.9.7.1.1, 2.9.7.2.1.1–2, and 2.9.7.2.3.1
Access Behavioral Care FY 2017–2018 Site Review Report Page A-37 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score Findings: Based on the desk review of policies and procedures, HSAG determined that ABC’s policies did include a process for ensuring that laboratory- testing sites have either a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver or a certificate of registration along with a CLIA registration number. During the on-site review ABC staff members confirmed that this was not a part of ABC’s credentialing process and that hospital laboratories were used by members. ABC staff corrected this oversight in the credentialing form immediately. Required Actions: ABC must ensure that it develops and adheres to a documented process whereby all laboratory-testing sites providing services to ABC members have either a CLIA Certificate of Waiver or a certificate of registration along with a CLIA registration number. 3. The Contractor’s provider selection policies and procedures • PNS202 Selection and Retention of Providers ABC-D include provisions that the Contractor does not: • CR301 Provider Credentialing and Met • Discriminate against particular providers for the Recredentialing Partially Met participation, reimbursement, or indemnification of any • CR305 Assessment of Organizational Not Met provider who is acting within the scope of his or her Providers N/A license or certification under applicable State law, solely
on the basis of that license or certification. ABC-NE • Discriminate against particular providers that serve high- Met risk populations or specialize in conditions that require Partially Met costly treatment. Not Met N/A 42 CFR 438.12(a)(1) and (2) 42 CFR 438.214(c)
Contract Amendment 7: Exhibit A3—2.5.14.1 and 2.9.7.1.3
Access Behavioral Care FY 2017–2018 Site Review Report Page A-38 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score 4. If the Contractor declines to include individual or groups of • CR301 Provider Credentialing & ABC-D providers in its network, it must give the affected providers Recredentialing Met written notice of the reason for its decision. • CR305 Assessment of Organizational Partially Met This is not construed to: Providers Not Met
• Require the Contractor to contract with providers beyond N/A
the number necessary to meet the needs of its members. • Preclude the Contractor from using different ABC-NE reimbursement amounts for different specialties or for Met different practitioners in the same specialty. Partially Met • Preclude the Contractor from establishing measures that Not Met are designed to maintain quality of services and control N/A costs and are consistent with its responsibilities to members.
42 CFR 438.12(a-b)
Contract Amendment 7: Exhibit A3—2.5.14.1 5. The Contractor may not knowingly have a director, officer, • CMP206 Sanction and Exclusion Screening ABC-D partner, employee, consultant, subcontractor, provider, or • CR301 Provider Credentialing & Met owner (owning 5 percent or more of the contractor’s equity) Recredentialing Partially Met who is debarred, suspended, or otherwise excluded from Not Met participation in federal healthcare programs. • CR305 Assessment of Organizational Providers N/A • The Contractor shall not employ or contract with any • CR DP04 Ongoing Monitoring of Providers individual or entity who has been excluded from ABC-NE participation in Medicaid by the U.S. Department of • CMP DP08 Compliance Program Operations Met Health and Human Services Office of Inspector General Manual Partially Met (HHS-OIG). • LGL DP02 Disclosure or Change in Ownership Not Met • The Contractor has procedures to provide the Department and Control N/A written disclosure of ownership and control within 35
Access Behavioral Care FY 2017–2018 Site Review Report Page A-39 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score days after any change in ownership of the managed care entity. • The Contractor shall, prior to hire or contracting, and at least monthly thereafter, screen all of its employees and contractors against the HHS-OIG’s List of Excluded Individuals (LEIE) to determine whether they have been excluded from participation in Medicaid. • The Contractor has procedures to provide to the Department written disclosure of any prohibited affiliation within five (5) business days of discovery.
42 CFR 438.214(d) 42 CFR 438.610(a-c) 42 CFR 438.608(c)(1-2)
Contract Amendment 7: Exhibit A3—2.9.7.3.3.2, 2.9.7.3.3.7, 2.9.10.9, 2.10.5.2, 2.10.5.3.7.2 6. The Contractor does not prohibit, or otherwise restrict health • CS212 Member Rights & Responsibilities ABC-D care professionals, acting within the lawful scope of practice, • Provider Manual Page 11 Met from advising or advocating on behalf of the member who is Partially Met the provider’s patient, for the following: Not Met • The member’s health status, medical care, or treatment N/A options—including any alternative treatments that may be self-administered. ABC-NE • Any information the member needs in order to decide Met among all relevant treatment options. Partially Met • The risks, benefits, and consequences of treatment or non- Not Met treatment. N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-40 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score • The member’s right to participate in decisions regarding his or her healthcare, including the right to refuse treatment and to express preferences about future treatment decisions.
42 CFR 438.102(a)(1)
Contract Amendment 7: Exhibit A3—2.10.17.1 7. If the Contractor objects to providing a service on moral or • Provider Manual Page 11 ABC-D religious grounds, the Contractor must furnish information Met about the services it does not cover: Partially Met • To the State upon contracting or when adopting the policy Not Met during the term of the contract. N/A • To members before and during enrollment. • To members within 90 days after adopting the policy with ABC-NE respect to any particular service. Met Partially Met 42 CFR 438.102(b) Not Met
N/A Contract Amendment 7: Exhibit A3—2.10.18.1 and 2.10.18.3
Access Behavioral Care FY 2017–2018 Site Review Report Page A-41 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score 8. The Contractor has administrative and management • Compliance Plan ABC-D arrangements or procedures, including a compliance program • Code of Conduct Met to detect and prevent fraud, waste, and abuse, and which • CMP206 Sanctions Screening Partially Met includes: • CMP211 Fraud, Waste and Abuse Not Met • Written policies and procedures and standards of conduct • CMP212 False Claims Act N/A that articulate the Contractor’s commitment to comply • CMP213 Internal Compliance Reviews with all applicable federal, State, and contract • Board of Directors Finance Audit and ABC-NE requirements. Compliance Committee Charter (available to Met review onsite) • The designation of a compliance officer who is Partially Met responsible for developing and implementing policies, • CMP204 Compliance Training and Education Not Met procedures, and practices to ensure compliance with • Compliance Acknowledgement Signed by N/A requirements of the contract and who reports directly to Every Employee
the CEO and Board of Directors. • CMP DP08 Compliance Operations Manual, • The establishment of a compliance committee of the specifically following sections: Board of Directors and at the senior management level, o Responding to Issues charged with overseeing the organization’s compliance o Complaint and Hotline Reports program. o Reporting Suspected Provider or Member Fraud • Training and education of the compliance officer, • QM302- Review of Provider Medical Records management, and organization’s staff members for the • QM DP06 ABC 411 and 137 Encounter federal and State standards and requirements under the Validation Audit contract.
• Effective lines of communication between the compliance officer and the Contractor’s employees. • Enforcement of standards through well-publicized disciplinary guidelines. • Implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-42 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score • Procedures for prompt response to compliance issues as they are raised, investigation of potential compliance problems identified in the course of self-evaluation and audits, correction of such problems quickly and thoroughly to reduce the potential for reoccurence, and ongoing compliance with the requirements under the contract. 42 CFR 438.608(a)(1)
Contract Amendment 7: Exhibit A3—2.9.3.1, 2.9.3.1.1.1–2, 2.9.3.1.3–7 9. The Contractor’s administrative and management procedures • CMP 212 False Claims Act ABC-D to detect and prevent fraud, waste, and abuse include: • CMP DP08 Compliance Program Operations Met • Written policies for all employees, contractors or agents Manual, Sections: Partially Met that provide detailed information about the False Claims o Reporting Suspected Provider or Member Not Met Act, including the right of employees to be protected as Fraud N/A HCPF Payment Suspension Requests whistleblowers. o
• Provisions for prompt referral of any potential fraud, ABC-NE waste, or abuse to the State Medicaid program integrity Met unit and any potential fraud to the State Medicaid Fraud Partially Met Control Unit. Contractor provides to the Department: Not Met ̶ Verbal report immediately. N/A ̶ Written report in three (3) business days. • Provisions for suspension of payments to a network provider for which the State determines there is credible allegation of fraud.
42 CFR 438.608(a)(6-8)
Contract Amendment 7: Exhibit A3—2.12.1, 2.9.3.2.1–2, 2.9.3.4.1, 2.9.3.4.4
Access Behavioral Care FY 2017–2018 Site Review Report Page A-43 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score 10. The Contractor’s compliance program includes: • CS DP25 Change in Member Status ABC-D • Provision for prompt notification to the Department about • ADM300 Provider Terminations Met member circumstances that may affect the member’s Partially Met eligibility, including change in residence and member Not Met death. N/A • Provision for notification to the State about changes in a network provider’s circumstances that may affect the ABC-NE provider’s eligibility to participate in the managed care Met program, including termination of the provider agreement Partially Met with the Contractor. Not Met
42 CFR 438.608(a)(3-4) N/A
Contract Amendment 7: Exhibit A3—2.9.3.2.1–2, 2.10.15.2 11. The Contractor’s compliance program includes provision for • ABC DP01 Member Services Verification Plan ABC-D prompt reporting (to the State) of all overpayments identified • CLM DP10 Claims Overpayments Met or recovered, specifying the overpayments due to potenial • CMP DP08 Compliance Program Operations Partially Met fraud. Manual, Overpayment Section Not Met • The Contractor screens all provider claims, collectively • QM302- Review of Provider Medical Records N/A and individually, for potential fraud, waste, or abuse— • QM DP06 ABC 411 and 137 Encounter including mechanisms to identify overpayments to Validation Audit ABC-NE providers and to report suspected instances of up-coding, • Current Provider Manual, pg 48. Met unbundling of services, services that were billed for but • New Provider Manual - not yet published Partially Met never rendered, and inflated bills for services and goods (available for review onsite) Not Met provided. • Colorado Access website “Non-Clinical N/A • The Contractor has procedures for provision of a method Adjustment/Appeal Process Request”
to verify on a regular basis, by sampling or other methods, whether services represented to have been delivered by Claims/Encounter processing audits and edits: network providers were received by members. We use several mechanisms to verify that provider
Access Behavioral Care FY 2017–2018 Site Review Report Page A-44 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score - The Contractor provides individual notices to all or a billing and payment accurately reflect delivered sample of members who received services to verify services. Our claims system is configured to and report whether services billed by providers were validate member eligibility, covered diagnosis, actually received by members. covered services, and also identifies duplicate • The Contractor has a mechanism for a network provider payments and overpayments. to report to the Contractor when it has received an overpayment, to return the overpayment to the Contractor We utilize the TriZetto QNXT claims/encounter within 60 calendar days of identifying the overpayment, processing system. Within this system, paper and and to notify the Contractor in writing of the reason for electronic claims and encounters are electronically the overpayment. matched to the appropriate member and provider. Once a member and provider are established, the • The Contractor has procedures to identify to the system runs through a series of automated Department within 60 calendar days of any capitation adjudication rules that are administered within each payments or other payments in excess of the amounts member’s eligibility and benefit package. The specified in the contract. benefit package contains covered services and • The Contractor reports annually to the State on recoveries codes, benefit limitations, authorization rules, and of overpayments. member responsibility (i.e., copayments), if applicable. Then, we calculate the provider 42 CFR 438.608(a)(5), (c)(3), and (d)(2) and (3) reimbursement amount from the fee schedule attached to that provider, under appropriate Contract Amendment 7: Exhibit A3—2.9.3.1.8, 2.9.3.1.1.3–9, contract and line of business, and then the claim is 2.9.3.2.1–2, and 5.2.1.1, ready for payment. In addition to payment rules within the provider and benefit setup, we also apply system-generated adjudication edits. These include validations of the service and diagnosis codes, as well as ensuring the claim was submitted within the timely filing requirements. The system also uses logic to check for duplicate claims submission to ensure that duplicate payments are not made. We routinely
Access Behavioral Care FY 2017–2018 Site Review Report Page A-45 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score audit system setup and reimbursement accuracy to ensure these payment rules are working correctly. We also utilize two McKesson tools: ClaimCheck and Policy Administration Module (PAM), which are integrated with the TriZetto QNXT transaction system. These tools are configured to edit claims against the requirements of the Uniform Services Coding Standards Manual by reviewing for coding utilization limits, invalid code combinations, correct modifiers, and place of service edits. With TriZetto, we have systems in place to flag and monitor outliers and unusual claim submissions for audit. A number of automated tools support this function. For example, controls are in place to identify high cost claims for review prior to payment. Colorado Access and Trizetto each employ operations/claims auditors who are specifically trained and experienced with reviewing claims/encounters against payment and processing policies and procedures. These claims auditors randomly audit at least three percent of claims processed daily. They audit for payment and processing accuracy for claims that were auto- adjudicated (i.e., without manual intervention), as well as claims we processed manually.
We contract with external audit vendors to perform various post-payment audits, and these contractors are trained in recognizing potential fraud, waste, and abuse issues:
Access Behavioral Care FY 2017–2018 Site Review Report Page A-46 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score • SCIO – reviews facility claims for coding accuracy, up-coding, high-dollar claim reviews, and specialty audits, such as infusion/DME audits. • Optum – conducts reviews at hospitals to identify credit balances and overpayment. • First Recovery Group (FRG) – reviews claims paid for potential subrogation recovery opportunities.
Procedures to identify to the Department within 60 calendar days of any capitation payments or other payments in excess of the amounts specified in the contract: The Department provides a list/files to Colorado Access of the members and the applicable capitation rate and payment. The Department also identifies errors and automatically adjusts error payments in following months. 12. The Contractor ensures that all network providers are • CR301 Provider Credentialing and ABC-D enrolled with the State as Medicaid providers consistent Recredentialing Met with the provider disclosure, screening, and enrollment • CR305 Organizational Providers Credentialing Partially Met requirements of the State. Not Met 42 CFR 438.608(b) N/A
Contract Amendment 7: Exhibit A3—2.5.9.12 ABC-NE Met Partially Met Not Met N/A
Access Behavioral Care FY 2017–2018 Site Review Report Page A-47 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard VII—Provider Participation and Program Integrity Requirement Evidence as Submitted by the BHO Score 13. The Contractor provides that Medicaid members are not held • Professional Provider Agreement Template ABC-D liable for: o Section C.6, Met • The Contractor’s debts in the event of the Contractor’s • Colorado Access Provider Manual, Partially Met Pg 47-48, Hold Harmless Clause insolvency. o Not Met
• Covered services provided to the member for which the N/A State does not pay the Contractor. • Covered services provided to the member for which the ABC-NE State or the Contractor does not pay the healthcare Met provider that furnishes the services under a contractual, Partially Met referral, or other arrangement. Not Met • Payments for covered services furnished under a contract, N/A referral, or other arrangement to the extent that those
payments are in excess of the amount that the member would owe if the Contractor provided the services directly.
42 CFR 438.106
Contract Amendment 7: Exhibit A3—2.2.3, 2.10.14.2
Access Behavioral Care FY 2017–2018 Site Review Report Page A-48 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Results for Standard VII—Provider Participation and Program Integrity for ABC-D Total Met = 12 X 1.00 = 12 Partially Met = 1 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 13 Total Score = 12
Total Score ÷ Total Applicable = 92%
Results for Standard VII—Provider Participation and Program Integrity for ABC-NE Total Met = 12 X 1.00 = 12 Partially Met = 1 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 13 Total Score = 12
Total Score ÷ Total Applicable = 92%
Access Behavioral Care FY 2017–2018 Site Review Report Page A-49 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard IX—Subcontracts and Delegation Requirement Evidence as Submitted by the BHO Score 1. Notwithstanding any relationship(s) with any subcontractor, Note—This does not apply to provider ABC-D the Contractor maintains ultimate responsibility for adhering agreements (unless provider contracted to Met to and otherwise fully complying with all terms and perform responsibilities other than services to Partially Met conditions of its contract with the State. The Contractor must: members). Not Met
• Evaluate the prospective subcontractor’s ability to perform N/A the activities to be delegated. • ADM223 Delegation • Monitor the subcontractor’s performance on an ongoing basis ABC-NE and subject it to formal review according to a periodic • Delegation agreement template, Article Met schedule established by the State, consistent with industry B.1. (pg 5) (will be available for review on Partially Met standards or State laws and regulations. site) Not Met • Identify deficiencies or areas for improvement, and ensure N/A that the subcontractor takes corrective action.
42 CFR 438.230(b)(1)
Contract Amendment 7: Exhibit A3—3.1.5, 3.1.5.1, 3.1.5.3–4 2. All contracts or written arrangements between the Contractor and • ADM223 Delegation ABC-D any subcontractor specify: Met • The delegated activities or obligations and related reporting • Delegation agreement template, Article Partially Met responsibilities. B.1. (pg 5) (will be available for review on Not Met • That the subcontractor agrees to perform the delegated site) N/A activities and reporting responsibilities
• Provision for revocation of the delegation of activities or ABC-NE obligation or specify other remedies in instances where the Met State or Contractor determines that the subcontractor has Partially Met not performed satisfactorily. Not Met N/A 42 CFR 438.230(b)(2) and (c)(1)
Contract Amendment 7: Exhibit A3—3.1.5.1.2
Access Behavioral Care FY 2017–2018 Site Review Report Page A-50 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard IX—Subcontracts and Delegation Requirement Evidence as Submitted by the BHO Score 3. The Contractor’s written agreement with any subcontractor • ADM223 Delegation ABC-D includes: • Delegation agreement template, Article B.1. Met • The subcontractor’s agreement to comply with all (pg 5) (will be available for review on site) Partially Met applicable Medicaid laws and regulations, including Not Met
applicable sub-regulatory guidance and contract N/A provisions. ABC-NE 42 CFR 438.230 (c)(2) Met Partially Met Contract Amendment 7: Exhibit A—6.A Not Met N/A
4. The written agreement with the subcontractor includes: • ADM223 Delegation ABC-D • The State, CMS, the HHS Inspector General, the • Delegation agreement template, Article Met Comptroller General, or their designees have the right to B.1. (pg 5) (will be available for review on Partially Met audit, evaluate, and inspect any books, records, contracts, site) Not Met computer or other electronic systems of the N/A
subcontractor, or of the subcontractor’s contractor, that pertain to any aspect of services and activities performed, ABC-NE or determination of amounts payable under the Met Contractor’s contract with the State. Partially Met ̶ The subcontractor will make available, for purposes Not Met of an audit, its premises, physical facilities, N/A equipment, books, records, contracts, and computer
or other electronic systems related to Medicaid members.
Access Behavioral Care FY 2017–2018 Site Review Report Page A-51 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Standard IX—Subcontracts and Delegation Requirement Evidence as Submitted by the BHO Score ̶ The right to audit will exist through 10 years from the final date of the contract period or from the date of completion of any audit, whichever is later. ̶ If the State, CMS, or HHS Inspector General determines that there is a reasonable probability of fraud or similar risk, the State, CMS, or HHS Inspector General may inspect, evaluate, and audit the subcontractor at any time.
42 CFR 438.230(c)(3)
Contract Amendment 7: Exhibit A3—2.9.9.5
Access Behavioral Care FY 2017–2018 Site Review Report Page A-52 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix A. Colorado Department of Health Care Policy and Financing FY 2017–2018 Compliance Monitoring Tool for Access Behavioral Care—Denver and Access Behavioral Care—Northeast
Results for Standard IX—Subcontracts and Delegation for ABC-D Total Met = 4 X 1.00 = 4 Partially Met = 0 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 4 Total Score = 4
Total Score ÷ Total Applicable = 100%
Results for Standard IX—Subcontracts and Delegation for ABC-NE Total Met = 4 X 1.00 = 4 Partially Met = 0 X .00 = 0 Not Met = 0 X .00 = 0 Not Applicable = 0 X NA = NA Total Applicable = 4 Total Score = 4
Total Score ÷ Total Applicable = 100%
Access Behavioral Care FY 2017–2018 Site Review Report Page A-53 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
Appendix B. Record Review Tools
The completed record review tools follow this cover page.
Access Behavioral Care FY 2017–2018 Site Review Report Page B-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Appeals Record Review Tool for Access Behavioral Care-Denver
Review Period: July 1, 2017–December 31, 2017 Date of Review: November 7, 2017 Reviewer: Kathy Bartilotta Participating Health Plan Staff Member: Christine Gillespie
1 2 3 4 5 6 7 8 9 10 11 12 Acknowledgment Date Notice Sent Resolution Letter Resolution File Member Date Appeal Sent Within 2 Decision Maker Not Decision Maker Has Time Frame Resolution Within Includes Letter Easy to # ID # Received Working Days Previous Level Clinical Expertise Expedited Extended Letter Sent Time Frame Required Content Understand 1 *** 07/11/17 M N N/A M N M N Yes No Yes No 07/14/17 M N M N M N Comments: Expedited request; inpatient hospitalization; oral notice to provider as designated representative; appeal overturned denial. 2 *** 07/26/17 M N N/A M N M N Yes No Yes No 07/27/17 M N M N M N Comments: Expedited request; continued inpatient stay; provider was designated representative; appeal overturned denial. 3 *** 08/15/17 M N N/A M N M N Yes No Yes No 08/25/17 M N M N M N Comments: Inpatient hospitalization; retrospective review; provider was designated representative. 4 *** 08/15/17 M N N/A M N M N Yes No Yes No 08/18/17 M N M N M N Comments: Expedited request; residential treatment; appeal upheld; member notified orally. 5 *** 08/31/17 M N N/A M N M N Yes No Yes No 09/08/17 M N M N M N Comments: Member admitted to inpatient hospitalization despite authorization denial; provider appealed retrospectively as designated representative; appeal upheld. 6 M N N/A M N M N Yes No Yes No M N M N M N Comments: 7 M N N/A M N M N Yes No Yes No M N M N M N Comments: 8 M N N/A M N M N Yes No Yes No M N M N M N Comments: 9 M N N/A M N M N Yes No Yes No M N M N M N Comments: 10 M N N/A M N M N Yes No Yes No M N M N M N Comments:
Access Behavioral Care FY 2017–2018 Site Review Report Page B-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Appeals Record Review Tool for Access Behavioral Care-Denver
1 2 3 4 5 6 7 8 9 10 11 12 Acknowledgment Date Notice Sent Resolution Letter Resolution File Member Date Appeal Sent Within 2 Decision Maker Not Decision Maker Has Time Frame Resolution Within Includes Letter Easy to # ID # Received Working Days Previous Level Clinical Expertise Expedited Extended Letter Sent Time Frame Required Content Understand OS1 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS2 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS3 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS4 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS5 M N N/A M N M N Yes No Yes No M N M N M N
Comments: Do not score shaded columns below. Column Subtotal of
Applicable Elements 2 5 5 5 5 5 Column Subtotal of
Compliant (M) Elements 2 5 5 5 5 5
Percent Compliant (Divide Compliant by Applicable) 100% 100% 100% 100% 100% 100%
Key: M = Met; N = Not Met N/A = Not Applicable Total Applicable Elements 27
Total Compliant (M) Elements 27
Total Percent Compliant 100%
Access Behavioral Care FY 2017–2018 Site Review Report Page B-3 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Grievance Record Review Tool for Access Behavioral Care-Denver
Review Period: July 1, 2017–December 31, 2017 Date of Review: November 7, 2017 Reviewer: Gina Stepuncik Participating Health Plan Staff Member: Veronica Rodriguez
1 2 3 4 5 6 7 8 9 10 11 Acknowledgement Date of # of Resolved and Decision Maker Not Appropriate Level of Resolution Letter Resolution Letter Member Date Grievance Sent Within 2 Written Days to Notice Sent in Previous Level Expertise Includes Easy to File # ID # Received Working Days Disposition Notice Time Frame (If Clinical) (If Clinical) Required Content Understand 1 *** 07/13/17 Y N N/A 08/02/17 20 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 2 *** 08/10/17 Y N N/A 08/25/17 15 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 3 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 4 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 5 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 6 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 7 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 8 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 9 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 10 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments:
Access Behavioral Care FY 2017–2018 Site Review Report Page B-4 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Grievance Record Review Tool for Access Behavioral Care-Denver
1 2 3 4 5 6 7 8 9 10 11 Acknowledgement Date of # of Resolved and Decision Maker Not Appropriate Level of Resolution Letter Resolution Letter Member Date Grievance Sent Within 2 Written Days to Notice Sent in Previous Level Expertise Includes Easy to File # ID # Received Working Days Disposition Notice Time Frame (If Clinical) (If Clinical) Required Content Understand OS 1 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 2 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 3 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 4 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 5 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: Do not score shaded columns below. Column Subtotal of 2 2 0 0 2 2 Applicable Elements Column Subtotal of 2 2 0 0 2 2 Compliant (Yes) Elements
Percent Compliant 100% 100% NA NA 100% 100% (Divide Compliant by Applicable)
Key: Y = Yes; N = No Total Applicable Elements 8 N/A = Not Applicable
Total Compliant (Yes) Elements 8
Total Percent Compliant 100%
Access Behavioral Care FY 2017–2018 Site Review Report Page B-5 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Appeals Record Review Tool for Access Behavioral Care-Northeast
Review Period: July 1, 2017–December 31, 2017 Date of Review: November 7, 2017 Reviewer: Kathy Bartilotta Participating Health Plan Staff Member: Christine Gillespie
1 2 3 4 5 6 7 8 9 10 11 12 Acknowledgment Date Notice Sent Resolution Letter Resolution File Member Date Appeal Sent Within 2 Decision Maker Not Decision Maker Has Time Frame Resolution Within Includes Letter Easy to # ID # Received Working Days Previous Level Clinical Expertise Expedited Extended Letter Sent Time Frame Required Content Understand 1 *** 07/13/17 M N N/A M N M N Yes No Yes No 07/14/17 M N M N M N Comments: Residential treatment; no signature obtained; however, member verbal approval of appeal noted in record; denied on appeal; called member. 2 *** 08/16/17 M N N/A M N M N Yes No Yes No 08/18/17 M N M N M N Comments: Residential continued stay; provider request; appeal upheld denial decision. 3 *** 08/31/17 M N N/A M N M N Yes No Yes No 09/01/17 M N M N M N Comments: Member assigned CMHC as designated representative; appeal overturned denial. 4 *** 10/19/17 M N N/A M N M N Yes No Yes No M N M N M N Comments: Expedited request; provider served as designated representative; non-covered diagnosis—appeal upheld; oral notice to provider. 5 M N N/A M N M N Yes No Yes No M N M N M N Comments: 6 M N N/A M N M N Yes No Yes No M N M N M N Comments: 7 M N N/A M N M N Yes No Yes No M N M N M N Comments: 8 M N N/A M N M N Yes No Yes No M N M N M N Comments: 9 M N N/A M N M N Yes No Yes No M N M N M N Comments: 10 M N N/A M N M N Yes No Yes No M N M N M N Comments:
Access Behavioral Care FY 2017–2018 Site Review Report Page B-6 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Appeals Record Review Tool for Access Behavioral Care-Northeast
1 2 3 4 5 6 7 8 9 10 11 12 Acknowledgment Date Notice Sent Resolution Letter Resolution File Member Date Appeal Sent Within 2 Decision Maker Not Decision Maker Has Time Frame Resolution Within Includes Letter Easy to # ID # Received Working Days Previous Level Clinical Expertise Expedited Extended Letter Sent Time Frame Required Content Understand OS1 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS2 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS3 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS4 M N N/A M N M N Yes No Yes No M N M N M N Comments: OS5 M N N/A M N M N Yes No Yes No M N M N M N
Comments: Do not score shaded columns below. Column Subtotal of
Applicable Elements 1 4 4 4 4 4 Column Subtotal of
Compliant (M) Elements 0 4 4 4 4 4
Percent Compliant (Divide Compliant by Applicable) 0% 100% 100% 100% 100% 100%
Key: M = Met; N = Not Met N/A = Not Applicable Total Applicable Elements 21
Total Compliant (M) Elements 20
Total Percent Compliant 95%
Access Behavioral Care FY 2017–2018 Site Review Report Page B-7 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Grievance Record Review Tool for Access Behavioral Care-Northeast
Review Period: July 1, 2017–December 31, 2017 Date of Review: November 7, 2017 Reviewer: Gina Stepuncik Participating Health Plan Staff Member: Veronica Rodriguez
1 2 3 4 5 6 7 8 9 10 11 Acknowledgement Date of # of Resolved and Decision Maker Not Appropriate Level of Resolution Letter Resolution Letter Member Date Grievance Sent Within 2 Written Days to Notice Sent in Previous Level Expertise Includes Easy to File # ID # Received Working Days Disposition Notice Time Frame (If Clinical) (If Clinical) Required Content Understand 1 *** 07/05/17 Y N N/A 07/17/17 12 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 2 *** 07/27/17 Y N N/A 07/28/17 1 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: Colorado Access sent the resolution letter the day after the grievance receipt date; therefore, the grievance was acknowledged through the resolution letter, and a separate acknowledgement letter was not necessary. 3 *** 08/10/17 Y N N/A 08/30/17 20 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 4 *** 08/23/17 Y N N/A 09/12/17 20 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 5 *** 08/31/17 Y N N/A 09/20/17 20 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: Colorado Access discussed this grievance with the member in the member’s home, per the member’s request. Colorado Access sent a written acknowledgement letter and a written resolution letter to the member following the home visit. 6 *** 08/24/17 Y N N/A 09/12/17 19 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: This grievance was clinical in nature as it involved the administering of medications to the member while the member was in residential care. 7 *** 10/02/17 Y N N/A 10/20/17 18 Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 8 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: 9 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments:
Access Behavioral Care FY 2017–2018 Site Review Report Page B-8 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 Appendix B. Colorado Department of Health Care Policy and Financing FY 2017–2018 Grievance Record Review Tool for Access Behavioral Care-Northeast
1 2 3 4 5 6 7 8 9 10 11 Acknowledgement Date of # of Resolved and Decision Maker Not Appropriate Level of Resolution Letter Resolution Letter Member Date Grievance Sent Within 2 Written Days to Notice Sent in Previous Level Expertise Includes Easy to File # ID # Received Working Days Disposition Notice Time Frame (If Clinical) (If Clinical) Required Content Understand 10 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 1 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 2 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 3 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 4 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: OS 5 Y N N/A Y N Y N N/A Y N N/A Y N N/A Y N N/A Comments: Do not score shaded columns below. Column Subtotal of 6 7 1 1 7 7 Applicable Elements Column Subtotal of 6 7 1 1 7 7 Compliant (Yes) Elements
Percent Compliant 100% 100% 100% 100% 100% 100% (Divide Compliant by Applicable)
Key: Y = Yes; N = No Total Applicable Elements 29 N/A = Not Applicablea
Total Compliant (Yes) Elements 29
Total Percent Compliant 100%
Access Behavioral Care FY 2017–2018 Site Review Report Page B-9 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
Appendix C. Site Review Participants
Table C-1 lists the participants in the FY 2017–2018 site review of ABC-D and ABC-NE.
Table C-1—HSAG Reviewers and ABC and Department Participants HSAG Review Team Title Kathy Bartilotta Associate Director Gina Stepuncik Project Manager ABC Participants Title Bethany Hines Vice President, Program Services Christine E. Gillespie Manager, Clinical Appeals Manager Claudine McDonald Director, Member Engagement and Inclusion Crystal Garrett Compliance Specialist David Rastatter Director, Colorado Medicaid Denise Brelsford Configuration Elizabeth Strammiello Chief Compliance Officer Heidi Warner Marketing Janet Milliman Director CHP+, Pharmacy Jason Smith Provider Contracting Jenny Nate Department Director, Behavioral Health Kristin Brown Operations Manager, Behavioral Health Marty Janssen Deputy Director, Medicaid Michelle Tomsche Operations Director, Behavioral Health Rebecca Lynn Provider Contracting Reyna Garcia Sr. Director, Customer Service and Claim Appeals Robert Bremer Vice President, Integrated Care Tanya Lilly Grievance Manager Travis Roth Credentialing Manager Veronica Rodriguez Grievance Department Observers Title Russ Kennedy Quality/Compliance Specialist Teresa Craig Program and Contract Manager, CHP+
Access Behavioral Care FY 2017–2018 Site Review Report Page C-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
Appendix D. Corrective Action Plan Template for FY 2017–2018
If applicable, the BHO is required to submit a CAP to the Department for all elements within each standard scored as Partially Met or Not Met. The CAP must be submitted within 30 days of receipt of the final report. For each required action, the BHO should identify the planned interventions and complete the attached CAP template. Supporting documents should not be submitted and will not be considered until the CAP has been approved by the Department. Following Department approval, the BHO must submit documents based on the approved timeline.
Table D-1—Corrective Action Plan Process Step Action Step 1 Corrective action plans are submitted If applicable, the BHO will submit a CAP to HSAG and the Department within 30 calendar days of receipt of the final compliance site review report via email or through the file transfer protocol (FTP) site, with an email notification to HSAG and the Department. The BHO must submit the CAP using the template provided. For each element receiving a score of Partially Met or Not Met, the CAP must describe interventions designed to achieve compliance with the specified requirements, the timelines associated with these activities, anticipated training and follow-up activities, and documents to be sent following the completion of the planned interventions. Step 2 Prior approval for timelines exceeding 30 days If the BHO is unable to submit the CAP (plan only) within 30 calendar days following receipt of the final report, it must obtain prior approval from the Department in writing. Step 3 Department approval Following review of the CAP, the Department and HSAG will: • Approve the planned interventions and instruct the BHO to proceed with implementation, or • Instruct the BHO to revise specific planned interventions and/or documents to be submitted as evidence of completion and also to proceed with implementation. Step 4 Documentation substantiating implementation Once the BHO has received Department approval of the CAP, the BHO will have a time frame of six months to complete proposed actions and submit documents. The BHO will submit documents as evidence of completion one time only on or before the six-month deadline for all required actions in the CAP. (If necessary, the BHO will describe in the CAP document any revisions to the planned interventions that were required in the initial CAP approval document or determined by the health plan within the intervening time frame.)
Access Behavioral Care FY 2017–2018 Site Review Report Page D-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Step Action Step 5 Technical assistance HSAG will schedule with the BHO a one-time, interactive, verbal consultation and technical assistance session during the six-month time frame. The session may be scheduled at the health plan’s discretion at any time the health plan determines would be most beneficial. HSAG will not document results of the verbal consultation in the CAP document. Step 6 Review and completion Following a review of the CAP and all supporting documentation, the Department or HSAG will inform the BHO as to whether or not the documentation is sufficient to demonstrate completion of all required actions and compliance with the related contract requirements. Any documentation that is considered unsatisfactory to complete the CAP requirements at the six-month deadline will result in assignment as a delinquent corrective action that will be continued into the following compliance review year. (HSAG will list delinquent actions in the annual technical report and in the health plan’s subsequent year’s compliance site review report.)
The CAP template follows.
Access Behavioral Care FY 2017–2018 Site Review Report Page D-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Table D-2—FY 2017–2018 Corrective Action Plan for ABC-D and ABC-NE Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action 3. The Contractor makes written information HSAG found that the taglines describing how ABC-D and ABC-NE must ensure that all member available in prevalent non-English to request auxiliary aids and services including materials include taglines describing how to request languages in its service area and in written translation and oral interpretation, auxiliary aids and services including written alternative formats upon member request at while present, were not in 18-point font on translation and oral interpretation in 18-point font. no cost. either paper or electronic member materials, as • Written materials that are critical to required. obtaining services include: provider directories, member handbooks, appeal and grievance notices, and denial and termination notices. • All written materials for members must: ̶ Use easily understood language and format. ̶ Use a font size no smaller than 12 point. ̶ Be available in alternative formats and through provision of auxiliary aids and services that take into consideration the special needs of members with disabilities or limited English proficiency. ̶ Include taglines in large print (18 point) and prevalent non- English languages describing how to request auxiliary aids and services, including written translation or oral
Access Behavioral Care FY 2017–2018 Site Review Report Page D-3 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action interpretation and the toll-free and TTY/TDY customer service number, and availability of materials in alternative formats. ̶ Be available for immediate dissemination in that language.
42 CFR 438.10(d)(3) and (d)(6)
Contract Amendment 7: Exhibit A3—2.6.5.13.1–3, 2.6.5.13.6.1–3, 2.6.5.13.7, 2.6.5.13.10.1–4 Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-4 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action 4. If the Contractor makes information During the desk review process, HSAG ABC must develop a process to ensure that all available electronically—Information conducted an accessibility check on a few information on its website is readily accessible (i.e., provided electronically must meet the ABC Web pages using the WAVE Web complies with 508 guidelines, Section 504 of the following requirements: Accessibility Evaluation Tool. Through use of Rehabilitation Act, and W3C’s Web Content • The format is readily accessible (see the tool, HSAG discovered several general Accessibility Guidelines). definition of readily accessible accessibility errors and contrast errors on above). various Web pages. HSAG also ran an ABC must inform members in a prominent place of accessibility check on several PDF documents its website that information on the website is • The information is placed in a Web available for download from the ABC website. available in paper form upon request without site location that is prominent and Through use of the Adobe Acrobat Pro charge, and provided within five business days. readily accessible. accessibility checker, HSAG discovered • The information can be accessibility errors. HSAG repeated these electronically retained and printed. accessibility checks during the on-site review • The information complies with for educational purposes, and the same content and language requirements. outcomes were discovered. • The member is informed that the information is available in paper form without charge upon request, and is provided within five (5) business days.
42 CFR 438.10(c)(6)
Contract Amendment 7: Exhibit A3—2.6.5.3.6–8
Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-5 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-6 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action 5. The Contractor makes interpretation On its website, ABC included a function to While ABC does provide oral interpretation, and use services (for all non-English languages) decipher its webpages (not including PDF of auxiliary aids to members free of charge as available free of charge and notifies documents) into any one of over 50 languages. needed, ABC must notify members that these members that oral interpretation is ABC did not, however, include directly on its provisions are available and how to access them. available for any language and written website or within the associated PDF member During the on-site review, HSAG and ABC translation is available in prevalent materials notification to the member that oral discussed prominent places for disseminating this languages, and how to access them. interpretation in any language, as well as other information on the ABC website. • This includes oral interpretation and auxiliary aids, are available free of charge or use of auxiliary aids such as TTY/TDY how members may access them. and American Sign Language. • The Contractor notifies members that auxiliary aids and services are available upon request and at no cost for members with disabilities, and how to access them.
42 CFR 438.10(d)(4) and (d)(5)
Contract Amendment 7: Exhibit A3—2.6.5.13.7–9 Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-7 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action 7. The Contractor makes available to members HSAG reviewed both the provider directory ABC must update its provider directory or online in paper or electronic form the following and the “Find A Provider” feature on the ABC “Find A Provider” feature to better clarify what it information about contracted network website. While the provider directory did not defines as “disability access,” in agreement with the physicians (including specialists), contain all required information, the “Find A requirement. hospitals, pharmacies, and behavioral Provider” was a valuable resource that health providers, and long-term services contained comprehensive information in a and supports (LTSS) providers: searchable format. As discussed on-site, the • The provider’s name and group disability accommodation field did not define affiliation, street address(es), the accommodations available at each telephone number(s), Web site URL, provider’s location. Further research performed specialty (as appropriate), and by ABC during the on-site visit concluded that whether the providers will accept new only one area of disability access, such as members. handicap parking or a nearby public transit line, could qualify a provider as having • The provider’s cultural and “disability access.” The requirement, however, linguistic capabilities, including clarifies this to include accessible offices, languages (including American Sign exam rooms, and equipment. Language) offered by the provider or provider’s office, and whether the provider has completed cultural competency training. • Whether the provider’s office has accommodations for people with physical disabilities, including offices, exam rooms, and equipment.
(Note: Information included in a paper provider directory must be updated at least monthly, and electronic provider
Access Behavioral Care FY 2017–2018 Site Review Report Page D-8 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D and ABC-NE Requirement Findings Required Action directories must be updated no later than 30 calendar days after the Contractor receives updated provider information.)
42 CFR 438.10(h)(1-3)
Contract Amendment 7: Exhibit A3—2.6.5.8.1–3 Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-9 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D Only Requirement Findings Required Action 10. For any information provided to members During the desk review, HSAG found that ABC-D must remove its Member and Family by the Contractor, the Contractor ensures ABC had two member handbooks, the Health Handbook from its webpage to ensure that members that information is consistent with federal First Colorado member handbook and its own are not receiving conflicting or inaccurate requirements in 42 CFR 438.10. member handbook, on its website at the information about appeals and grievances. webpage coaccess.com/abc-denver-plan- 42 CFR 438.10 (b) documents-and-forms. During the on-site interview, ABC noted that this was unintentional and that it would be removed immediately. A week following the on-site review, the ABC-D Member and Family Handbook had not been removed. HSAG found that the ABC-D handbook contained information which conflicts with the Health First Colorado member handbook, which could be confusing to members. For example, the information ABC-D provided to members in the Member and Family Handbook had not been updated to reflect current time frames and procedures for grievances and appeals in accordance with 42 CFR §438.10 information requirements.
HSAG viewed a similar webpage for ABC-NE, which contained only a link to the Health First Colorado member handbook. Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-10 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard V—Member Information—ABC-D Only Requirement Findings Required Action Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-11 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VI—Grievance System—ABC-D and ABC-NE Requirement Findings Required Action 7. Members may file a grievance at any time. The policy ADM203—Member Grievance ABC must ensure that the QOCC policy is updated Process stated that a member may file a to reflect that a quality of care grievance may be 42 CFR 438.402(c)(2)(i) grievance at any time. However, the related filed by a member at any time. Policy revisions must policy, QM201—Quality of Care Concern be approved by appropriate governing bodies and Contract Amendment 7: Exhibit A3—2.6.4.5.3 (QOCC) Investigations stated that a member implemented, including any applicable staff 10 CCR 2505-10—8.209.5.A may file a quality of care grievance within 30 training. days of the incident. Staff members stated that the standard operating procedure has always been to accept a member grievance of any nature at any time. During on-site review, staff members corrected the QOCC policy to comply with requirements and correlate with the member grievance policy. Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-12 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VI—Grievance System—ABC-NE Only Requirement Findings Required Action 15. The Contractor sends the member written Appeal policies and procedures accurately ABC-NE must have mechanisms to ensure that acknowledgement of each appeal within addressed written acknowledgement of written acknowledgement of a standard appeal two (2) working days of receipt, unless the appeals—unless expedited—within two request is sent to the member or designated member or designated client representative working days. This was demonstrated in 100 representative, consistent with ABC policies and requests an expedited resolution. percent of ABC-D record reviews. However, procedures. HSAG noted one ABC-NE appeal record 42 CFR 438.406(b)(1) which failed to send an acknowledgement letter within two days of receipt of the appeal Contract Amendment 7: Exhibit A3—2.6.4.1 10 CCR 2505-10—8.209.4.D request. Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-13 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VI—Grievance System—ABC-D and ABC-NE Requirement Findings Required Action 23. If, at the member’s request, the Contractor The policy ADM 219—Member Appeal ABC must remove inaccurate statements as noted in continues or reinstates the benefits while Processes addressed all bullets outlined in the the member appeals policy as well as any related the appeal or State fair hearing is pending, requirement. However, the policy also included member or provider communications (e.g., appeal the benefits must be continued until one of an additional criterion: until “the time period or resolution or adverse determination letters). Policy the following occurs: service limits of the previously authorized revisions must be approved by appropriate • The member withdraws the appeal or service has been met.” This criterion is not governing bodies and implemented, including any request for a State fair hearing. applicable to the length of time that benefits applicable staff training. • The member fails to request a State fair will be continued. During on-site review, staff hearing and continuation of benefits members corrected the applicable language in within 10 calendar days after the the policy to comply with requirements. Contractor sends the notice of an adverse However, the revised policy was not effective resolution to the member’s appeal. during the review period; and ABC cannot be credited with this revision pending approval, • A State fair hearing officer issues a implementation, and any applicable staff hearing decision adverse to the member. training. 42 CFR 438.420(c) Contract Amendment 7: Exhibit A3—2.6.4.8.2 10 CCR 2505-10—8.209.4.U Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-14 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VI—Grievance System—ABC-D and ABC-NE Requirement Findings Required Action 27. The Contractor provides the information The Colorado Access Professional Provider ABC must develop accessible and timely about the grievance appeal and State fair Agreement incorporates the provider manual mechanisms to inform providers and subcontractors hearing system to all providers and by reference. The ABC provider manual about the grievance, appeal, and SFH system in subcontractors at the time they enter into a included a limited description regarding the sufficient detail to address all federal and State contract. The information includes: member’s right to file grievances and appeals, requirements for provider information. • The member’s right to file grievances and included no detailed information to address and appeals. the required components of the information • The requirements and time frames for about the grievance appeal and SFH system. filing grievances and appeals. The manual directed the provider to two different Colorado Access website locations to • The right to a State fair hearing after find detailed instructions or procedures related the Contractor has made a decision on to grievances and appeals. HSAG found that no an appeal which is adverse to the detailed procedures for appeals or grievances member, including how members were located at either specified link. In obtain a hearing, and the representation addition, the provider manual included no rules at a hearing. information on appeals process available under • The availability of assistance in the the Child Mental Health Treatment Act filing processes. (CMHTA). During on-site interviews, staff • The toll-free number to file orally. members stated that the entire provider manual • The fact that, when requested by the was being rewritten and would be available for member: publication on or after December 1, 2017. The ̶ Services that the Contractor seeks new provider manual will link the provider to to reduce or terminate will the revised ADM203—Member Grievance continue if the appeal or request for Process and ADM219—Member Appeal State fair hearing is filed within the Process policies on the provider website. time frames specified for filing. ̶ The member may be required to pay the cost of services furnished
Access Behavioral Care FY 2017–2018 Site Review Report Page D-15 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VI—Grievance System—ABC-D and ABC-NE Requirement Findings Required Action while the appeal or State fair hearing is pending, if the final decision is adverse to the member. • Appeals process available under the Child Mental Health Treatment Act (CMHTA), if residential services are denied. • Any State-determined provider’s appeal rights to challenge the failure of the organization to cover a service.
42 CFR 438.414 42 CFR 438.10(g)(xi)
Contract Amendment 7: Exhibit A3—2.6.4.4 10 CCR 2505-10—8.209.3.B Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-16 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VII—Provider Participation and Program Integrity—ABC-D and ABC-NE Requirement Findings Required Action 2. The Contractor follows a documented Based on the desk review of policies and ABC must ensure that it develops and adheres to a process for credentialing and procedures, HSAG determined that ABC’s documented process whereby all laboratory-testing recredentialing that complies with the policies did include a process for ensuring that sites providing services to ABC members have State’s policies for credentialing. laboratory-testing sites have either a Clinical either a CLIA Certificate of Waiver or a certificate • The Contractor uses National Laboratory Improvement Amendments (CLIA) of registration along with a CLIA registration Committee for Quality Assurance Certificate of Waiver or a certificate of number. (NCQA) credentialing and registration along with a CLIA registration recredentialing standards and number. During the on-site review ABC staff guidelines as the uniform and required members confirmed that this was not a part of standards for all contracts. ABC’s credentialing process and that hospital laboratories were used by members. ABC staff • The Contractor ensures that all corrected this oversight in the credentialing laboratory-testing sites providing services under the Contract shall have form immediately. either a Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver or a Certificate of Registration along with a CLIA registration number.
42 CFR 438.214(b) and (e)
Contract Amendment 7: Exhibit A3—2.9.7.1.1, 2.9.7.2.1.1–2, and 2.9.7.2.3.1 Planned Interventions:
Person(s)/Committee(s) Responsible and Anticipated Completion Date:
Training Required:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-17 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX D. CORRECTIVE ACTION PLAN TEMPLATE FOR FY 2017–2018
Standard VII—Provider Participation and Program Integrity—ABC-D and ABC-NE Requirement Findings Required Action Monitoring and Follow-Up Planned:
Documents to be Submitted as Evidence of Completion:
Access Behavioral Care FY 2017–2018 Site Review Report Page D-18 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118
Appendix E. Compliance Monitoring Review Protocol Activities
The following table describes the activities performed throughout the compliance monitoring process. The activities listed below are consistent with CMS’ EQR Protocol 1: Assessment of Compliance with Medicaid Managed Care Regulations: A Mandatory Protocol for External Quality Review (EQR), Version 2.0, September 2012.
Table E-1—Compliance Monitoring Review Activities Performed For this step, HSAG completed the following activities: Activity 1: Establish Compliance Thresholds Before the site review to assess compliance with federal Medicaid managed care regulations and contract requirements: • HSAG and the Department participated in meetings and held teleconferences to determine the timing and scope of the reviews, as well as scoring strategies. • HSAG collaborated with the Department to develop monitoring tools, record review tools, report templates, on-site agendas; and set review dates. • HSAG submitted all materials to the Department for review and approval. • HSAG conducted training for all site reviewers to ensure consistency in scoring across plans. Activity 2: Perform Preliminary Review • HSAG attended the Department’s Behavioral Health Quality Improvement Committee (BQuIC) meetings and provided group technical assistance and training, as needed. • Sixty days prior to the scheduled date of the on-site portion of the review, HSAG notified the BHO in writing of the request for desk review documents via email delivery of the desk review form, the compliance monitoring tool, and an on-site agenda. The desk review request included instructions for organizing and preparing the documents related to the review of the three standards and on-site activities. Thirty days prior to the review, the BHO provided documentation for the desk review, as requested. • Documents submitted for the desk review and on-site review consisted of the completed desk review form, the compliance monitoring tool with the BHO’s section completed, policies and procedures, staff training materials, administrative records, reports, minutes of key committee meetings, and member and provider informational materials. The BHOs also submitted a list of all Medicaid appeals and grievances that occurred between July 1, 2017, and December 31, 2017. HSAG used a random sampling technique to select records for review during the site visit. • The HSAG review team reviewed all documentation submitted prior to the on-site portion of the review and prepared a request for further documentation and an interview guide to use during the on-site portion of the review.
Access Behavioral Care FY 2017–2018 Site Review Report Page E-1 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118 APPENDIX E. COMPLIANCE MONITORING REVIEW PROTOCOL ACTIVITIES
For this step, HSAG completed the following activities: Activity 3: Conduct Site Visit • During the on-site portion of the review, HSAG met with the BHO’s key staff members to obtain a complete picture of the BHO’s compliance with contract requirements, explore any issues not fully addressed in the documents, and increase overall understanding of the BHO’s performance. • HSAG reviewed a sample of administrative records to evaluate implementation of Medicaid managed care regulations related to BHO appeals and grievances. • Also while on-site, HSAG collected and reviewed additional documents as needed. (HSAG reviewed certain documents on-site due to the nature of the document—i.e., certain original source documents were confidential or proprietary, or were requested as a result of the pre-on-site document review.) • At the close of the on-site portion of the site review, HSAG met with BHO staff and Department personnel to provide an overview of preliminary findings. Activity 4: Compile and Analyze Findings • HSAG used the FY 2017–2018 Site Review Report Template to compile the findings and incorporate information from the pre-on-site and on-site review activities. • HSAG analyzed the findings. • HSAG determined opportunities for improvement, recommendations, and required actions based on the review findings. Activity 5: Report Results to the State • HSAG populated the report template. • HSAG submitted the draft site review report to the BHO and the Department for review and comment. • HSAG incorporated the BHO’s and Department’s comments, as applicable, and finalized the report. • HSAG distributed the final report to the BHO and the Department.
Access Behavioral Care FY 2017–2018 Site Review Report Page E-2 State of Colorado ABC_CO2017-18_BHO_SiteRev_F1_0118